Certificate of Medical Necessity /

Growth Hormone Therapy

Fax this completed Certificate of Medical Necessity form along with other required 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: / Statewide Fax Number: 1-904-905-9849
Section A

Physician Information

Name:

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BCBSF Number:

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National Provider Identifier (NPI):

Street Address:

City:

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County:

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State:

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ZIP:

Telephone Number:

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Fax Number:

Contact Name:

Facility Information

Name:

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BCBSF Number:

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National Provider Identifier (NPI):

Street Address:

City:

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County:

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State:

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ZIP:

Telephone Number:

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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 <10% for gestational age?
Yes No / At 24 months of age, has patient failed to demonstrate catching up to growth AND is below the 3rd percentile in height and weight for chronological age or height and weight <2 SD below the mean for chronological age?
Growth hormone deficiency in adults 21 years of age and older OR adolescents whose epiphyses have closed
Yes No / Does patient have laboratory evidence of GH deficiency and the deficiency is the result of pituitary disease, hypothalamic disease, pituitary tumor, surgical damage, cranial irradiation, Sheehan’s syndrome, autoimmune hypophysitis, sarcoidosis trauma, or childhood onset deficiency?
If yes, indicate which conditions patient has:
Growth hormone therapy in patients with AIDS-wasting syndrome
Yes No / Has patient been diagnosed with AIDS?
Yes No / Does patient exhibit unexplained baseline weight loss of more than 10% in the past 12 months or a body-mass index (BMI) of less than 20 that cannot be attributed to any other condition other than HIV infection?
Growth hormone therapy in patients with short bowel syndrome
Yes No / Does patient have short bowel syndrome as a result of resected or damaged bowel with chronic diarrhea, weight loss, electrolyte imbalances, malnutrition, dehydration, and malabsorption of fats, vitamins and minerals?
Yes No / Is patient dependent on specialized nutritional support needs including dietary adjustments such as a high carbohydrate, low fat diet, enteral feedings, parenteral nutrition, fluid, and micronutrient supplements?

Comments:


My signature below certifies that the information submitted on this form is accurate and these services are medically necessary.

Ordering Physician’s Signature: / Date:

Certificate of Medical Necessity: Growth Hormone Therapy 2