Procedure for Growth Hormone Testing
1. The doctor must give a written order to Karen (X106). She will schedule the test.
2. The CPT codes for the growth hormone tests are simply office visits and labwork. There is no “procedure code” for the test. Therefore, the insurance company will NOT tell us what it will pay until we submit the claim. Please note that you may be responsible for paying a portion of the test. Once your child has been determined to be a candidate, the growth hormone approval process begins.
Procedure for Growth Hormone Approval
- The physician must first write a prescription for the growth hormone. This goes to Karen (X106) who begins the paperwork process.
- Karen submits paperwork to Access Solutions (Genentech), Bridge (Pfizer), Connections (Serono), Nordistart (Novo), HRC (Lilly), Growth Solution (TevTropin), Caremark or Premier Kids Care depending on the prescription written. The submitted paperwork is used to research benefits, determine distributor for growth hormone, and submit for medical review. The medical review process may take up to 90 days for approval, depending on your particular insurance plan. If the growth hormone is denied, the appeal process can take another 6 months. The growth hormone distributor is usually determined by the insurance plan. If mail order is necessary, Access Solutions, etc. will arrange for first delivery.
- You will also need to fill out paperwork and register with the mail order pharmacy. You must be there to sign for shipment (drug requires refrigeration). We prefer to have the first shipment of medication sent to our office to assure that it is here for teaching.
- At the same time your physician will write an order for an MRI of the pituitary. This must be done before starting growth hormone (exceptions are Turner Syndrome and Prader-Willi Syndrome). The MRI is scheduled by the doctor’s nurse and may require precertification by your insurance company.
- To determine coverage for growth hormone, please call your insurance company. The diagnosis codes may include 253.3 (growth hormone deficiency) or idiopathic short stature (783.43). The code for the drug itself is J2941.
- Once the following are in place:
a. Medication approved
b. Medication received by office (unless mail order)
c. MRI results received
You should call Karen (X106) or Corinda (X120) to set up a teaching appointment. The first shipment of growth hormone should be sent to Pediatric Endocrine; subsequent deliveries can be sent to your home or workplace. You must watch the medication DVD before the class, and your child must be present for the teaching.
Remember, this is a lengthy process. Your child will not be started on growth hormone until all of these procedures have been completed. Please be patient!
Questions for Insurance Companies in Regards to Growth Hormone Coverage
If calling an insurance company to verify if growth hormone is covered, how it will be paid, and what the benefits are, below is a list of questions that will assist in obtaining accurate information.
- Are
self injectable drugs covered?
If so: Is growth hormone covered? - Is it covered under major medical
or the PBM (Pharmacy Benefit Manager)?
If it is covered under major medical:
What are the benefits: Deductible? Out of pocket? Lifetime max? Annual or lifetime cap?
If it is covered under the PBM:
What are the benefits: Flat copay? Percentage? Annual or lifetime cap? - Does it require an authorization?
If so: Who does the authorization (PBM, major medical, outside source) and what is their contact information? - What growth hormone drugs are on the formulary list and what tiers are they?
- Where/How
must patient obtain growth hormone:
• Can growth hormone be obtained through local pharmacy? If so, will patient be required to obtain “maintenance drug” through mail order after an allotted amount of prescription fills/refills?
• How many prescription fills/refills is patient allowed prior to being required to use mail order pharmacy?
• Does growth hormone have to be obtained from a specialty pharmacy? If so, which one? What is their contact information?
• Does growth hormone have to be obtained from the mail order pharmacy?
Growth Hormone Stimulation Testing and Preparation
The doctor has determined that your child should be tested for growth hormone deficiency. This is usually done because there is an abnormal growth rate for age, a crossing down in height percentiles, or a low somatomedin-C level (screening growth hormone level).
Testing for growth hormone deficiency is done in our office in an outpatient setting. An adult must accompany the child and the test will last about 3-4 hours. There is a TV with a DVD player and we try to make the patient as comfortable as possible. We have movies available, but you may want to bring your own.
After checking in, the patient will have an IV inserted from which multiple samples will be drawn at specified times from the same tubing. Drinking plenty of fluids for several days before the test helps to plump the veins and will make it much easier to get a good IV placement. These samples will measure the growth hormone and cortisol levels in response to two provocative agents that stimulate the pituitary gland to produce growth hormone. The first stimulant, L-dopa, is an oral medication in pill form. Halfway through the test, the patient will be given insulin through the IV to purposely make the blood sugar low (this is a stimulus to the pituitary gland to release growth hormone). Samples of blood will be drawn from the IV line throughout the test.
Please make sure you bring a snack/lunch for your child to eat after the test is over. It must be eaten before the patient can leave the office.
The following preparations will ensure that the procedure will be easiest to complete and that the results will be accurate:
1. ONE WEEK PRIOR TO TEST: VERY IMPORTANT!!! NO CAFFEINE!
The patient should begin drinking 6-8 glasses of water/fluids per
day and continue this until the night before the test. This will make
it much easier to have a good, plump vein in which to put the IV. During
the summer months, please add even more fluid to this amount if your
child is active outside and perspiring. The child should not have any
caffeine the week before testing.
2. THREE-FOUR DAYS PRIOR TO TEST:
The patient should eat a high carbohydrate food plan that includes
cereals, breads, pastas, starchy vegetables, fruits, and fruit juices.
3. EVENING PRIOR TO TEST:
The patient should be given a large bedtime snack (around 10 PM)
which may consist of food such as a peanut butter or meat sandwich,
macaroni and cheese, pasta, a bowl of cereal with milk, or fruit
and yogurt.
4. MORNING OF TEST:
The patient may brush teeth and drink plain water, but NOTHING
TO EAT!! Please bring a lunch (sandwich, juice, crackers, fruit, etc.)
for your child to eat after the test.
If the patient takes any medications in the morning, please check with the doctor or nurse prior to the test date. ADD/ADHD medications are okay and encouraged the morning of the test.
Due to the small testing room, only one parent may accompany your child. Siblings cannot be accommodated. There is a DVD player available for your child’s enjoyment. We have a selection of DVD’s, but you are welcome to bring your own. Don’t forget to bring a snack!
