Growth hormone for a new member with cranial irradiation

[participant1]

If a member has growth hormone deficiency due to cranial irradiation is the provocative stimuli testing still required? We have a new member, who's been on growth hormone therapy prior to the enrollment but this person is not meeting our policy criteria for >2 provocative stimuli tests (the auxologic criteria have been met)...

[chantell.reagan]

The NICE guidance regarding the use of recombinant human growth hormone in children states that patients with cranial irradiation should have an appropriate growth hormone (GH) provocation test; however, only 1 test (as opposed to at least 2 for a primary deficiency) is required. Cigna's policy for GH is consistent with these recommendations. Also note that this specific issue is not addressed in the AACE guidelines, but it is stated that in cases of complete hypopituitarism it is possible to establish GH deficiency through IGF-I testing.

However, in theory, as this patient has been receiving therapy, GH provocative stimuli and IGF-I tests may not be appropriate unless treatment is discontinued and there is adequate washout period. Considering that GH deficiency is linked to a specific cause in this case (radiation therapy) and the patient has been receiving treatment, denial of coverage and interruption of therapy for the purposes of confirming diagnosis may not be clinically appropriate.


References

1. NHS. National Institute for Clinical Excellence. Guidance on the use of growth hormone (somatropin) in children with growth failure. June 2005. NICE guidance on growth hormone Accessed May 14, 2008.

2. Cigna. HealthCare Coverage Position. Coverage Position #4012. November 2007.
Cigna coverage position Accessed May 14,2008.

3. AACE. Medical guidelines for clinical practice for growth hormone use in adults and children, 2003 update.
AACE growth hormone guidelines Accessed May 14, 2008.