Growth Hormone Therapy CMN - BCBSFL
|Certificate of Medical Necessity |[pic] |
Growth Hormone Therapy
|Fax this completed Certificate of Medical Necessity form along with other required | |Statewide Fax Number: 1-904-905-9849 |
|documentation including the endocrinologist evaluation, growth chart, clinical | | |
|notes/history, and test results including GH stimulation test, genetic testing, bone | | |
|age, MRI and IGF-1 to: | | |
|Section A |
Physician Information
|Name: |BCBSF Number: |National Provider Identifier (NPI): |
|Street Address: |
|City: |County: |State: |ZIP: |
|Telephone Number: |Fax Number: |
|Contact Name: |
Facility Information
|Name: |BCBSF Number: |National Provider Identifier (NPI): |
|Street Address: |
|City: |County: |State: |ZIP: |
|Telephone Number: |Fax Number: |
|Contact Name: |
Member Information
|Last Name: |First Name: |
|Member/Contract Number (alpha and numeric): |Date of Birth: |
|Section B |
|Procedure Code (HCPCS): |Medication Name: |
|ICD-9 Code: |Diagnosis Description: |
|This medication is: administered by the Provider. self-administered by the patient. |
| Yes No N/A Is patient picking up medication at a retail pharmacy? |
| Yes No N/A Is provider buying the medication and billing BCBSF directly? |
| Yes No N/A Is provider obtaining medication from Caremark for drug replacement? |
|This is: an initial request. a continuation of therapy. |
| |
|If continuation, what date was therapy initiated? / Current Daily Dosage: |
| |
|If restart, what dates was therapy previously used? / Why was therapy stopped and restarted? |
|Prescribed Dosage: |Dosing Frequency: |Dosing administration route: |
|Section C |
|GH Stimulation Date: |Agent No. 1: |Peak Value: |Units: |
|GH Stimulation Date: |Agent No. 2: |Peak Value: |Units: |
|Height: cm / % / SDS: |Weight: cm / % / SDS: |Growth Velocity: cm/yr. |
|IGF-1: / Date Drawn: |Birth Weight: |Birth Length: |
|Bone Age by X-Ray: |Chronological Age: |Epiphysis Open? Yes No |
|Mother’s Height: / Unknown |Father’s Height: / Unknown |
|Section D |
Check the box and complete the questions applicable to the patient’s condition:
| Growth failure due to growth hormone deficiency (GHD) in children under the age of 21 years |
| Growth hormone therapy in children with chronic renal failure (before renal transplant) |
|Yes No |
|Has there been a reduction in the glomerulofiltration rate (GFR) or creatinine clearance (CrCL) to below 25% of normal level for at least 3 months? |
| |
|List or attach lab values: |
| |
|Yes No |
|Has nutritional status been optimized? |
| |
|Yes No |
|Have metabolic abnormalities such as acidosis, secondary to hyperthyroidism, |
|and under nutrition been corrected? |
| |
|Yes No |
|Has steroid usage been reduced to a minimum? |
| |
| Growth hormone therapy with Turner’s syndrome |
|Yes No |
|Does the peripheral blood karyotype show a 45, XO genotype? |
| |
| Growth hormone therapy with Noonan’s syndrome |
|Yes No |
|Does the patient have serious heart failure? |
| |
|Yes No |
|Are the IGF-1 levels and cardiac function monitored regularly? |
| |
| Growth hormone therapy in children with Short Stature Homeobox Gene (SHOX) deficiency |
| Growth hormone therapy with Prader-Willi syndrome |
|Yes No |
|Did patient have a normal sleep study performed prior to initiation of therapy? |
| |
|Yes No |
|Is micro-deletion in the long arm of chromosome 15 or 2 maternal chromosome 15 and no paternal chromosome 15, or non-functional paternal chromosome 15 present?|
| |
|Yes No |
|For continuation of therapy, has there been an increase in lean body mass and decrease in fat mass? |
| |
| Growth hormone therapy with Small for Gestational Age (SGA) |
|Yes No |
|Was birth weight less than 5th percentile for gestational age AND birth height ................
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