The era of managed care has brought more intense scrutiny of health care expenditures. Some of the earliest targets include high cost drugs and therapeutics such as those produced by recombinant DNA technology.

In July of 1989, Blue Cross and Blue Shield of Virginia implemented criteria for the use of exogenous human growth hormone. Eligibility criteria are: 1) growth hormone values of less than 10ng/ml in response to two provocative agents; and 2) growth rate of less than five centimeters per year in children older than two years. Because of proven response to therapy, girls with Turner's syndrome are covered without meeting the first criterion. Between 7/30/89 and 12/1/97, 400 cases have been reviewed by a pediatric endocrinologist. This number of cases represents approximately.022% of individuals covered by this insurer.

Of those reviewed, 328 cases (82%) were approved based on the “classical” definition of growth hormone deficiency. Sixteen of the patients had Turner's syndrome. The largest number of denials was for the diagnosis of neurosecretory defect in growth hormone secretion, a diagnosis not covered because of unproven therapeutic benefit.

In conclusion, pediatric endocrinologists in Virginia prescribe growth hormone for children in whom growth hormone deficiency is adequately documented in the majority of cases. Projected cost savings achieved by the medical reviews is over four million dollars, based on $18,000 per year per patient for an average treatment period of 3.2 years.