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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