Growth Hormone (GH) and Growth Hormone Antagonists (CPB 0170, reviewed 2026-06-26)

By June 26, 2026: Billing and clinical teams must implement precertification requirements for Somavert (contact Aetna at 866-752-7021 or fax 888-267-3277). Update EMR/billing systems to capture and validate the following for all somatropin product requests: (1) specific diagnosis confirmation (e.g., genetic testing for Prader-Willi, karyotyping for Turner syndrome); (2) pretreatment GH test results with peak levels meeting thresholds (ITT ≤5 ng/mL for adults, <10 ng/mL for pediatrics); (3) IGF-1 levels documented as SD below mean; (4) height velocity measurements (1-year data for age ≥2.5 years); (5) confirmation of open epiphyses via imaging. Providers must include these supporting documents with prior authorization requests. Before submitting claims, verify member meets specific criteria for their diagnosis category (pediatric GHD, Turner syndrome, Noonan syndrome, CKD, SGA, SHOX deficiency, Prader-Willi, congenital adrenal hyperplasia, cerebral palsy, cystic fibrosis, or Russell-Silver syndrome). For continuation therapy, document growth rate >2 cm/year or clinical reason for lower growth. Failure to submit required documentation and precertification will result in claim denials.