Appeal type: Formulary Exception
Decision: Overturned



Diagnosis: Obesity.
Treatment: Wegovy.
The health plan denied: Wegovy.
The determination is: Overturned.

The patient is a female being prescribed Wegovy for the treatment of obesity. The health plan denied coverage for the requested medication. They state that it is a covered benefit, but certain criteria must be met. They require an evaluation for potential medical causes of weight gain such as thyroid disease, depression, or medication side effects. They also require documentation regarding lifestyle modifications that will be used in conjunction with the medication. The requested medication cannot be used at the same time as other weight loss products. The plan reports that documentation was not provided to meet these criteria, and therefore the request was denied.
The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient has obesity, prediabetes, polycystic ovarian syndrome, hyperlipidemia, and hypertension. Her current body mass index (BMI) is 32.5. She has had a normal laboratory workup, including thyroid testing. She takes sertraline for anxiety and does not have any current depression symptoms; her obesity predates any anxiety issues. She has a plan for a healthy diet of vegetables and low sugar/starch intake. Her exercise plan is for 150 minutes per week. She is not taking any other weight loss medications. The prescriber feels that the patient meets the requested criteria and feels that it would be the most effective treatment for the patient. Recent progress notes from the patient's office visit were provided for review, which corroborate the information provided in the prescriber letter.
At issue is the drug Wegovy.
The health plan's determination of medical necessity is overturned in whole.
The patient's plan formulary covers the requested medication, Wegovy, with a prior authorization and when certain criteria are met. The plan states that several of those criteria have been met, but denied coverage because they did not have evidence that three of them were met. They are as follows:
1. Evidence that medical causes of obesity have been ruled out, including thyroid disease, depression, and medication side effect.
This criteria has been met. The patient's provider attested to normal thyroid testing, no depression, and no other causes of obesity have been found.
2. Lifestyle modification that will be used in conjunction with the requested medication.
This criteria has been met. The prescriber described the dietary approach that the patient will be using, as well as an exercise plan for 150 minutes of exercise per week. This recommendation is in line with the American Heart Association's weekly exercise recommendation.
3. The requested medication must not be used with any other weight loss product, including medications and supplements.
This criteria has been met. The patient's prescriber attested to this in her letter of support. Additionally, review of the office visit notes and current medication list support the documentation.
The patient therefore meets all of the plan criteria for prior authorization of the requested formulary drug, Wegovy. She also meets the Food and Drug Administration (FDA) approvable criteria with a BMI greater than 30. She has obesity related comorbidities including hypertension and hyperlipidemia. The requested medication is medically appropriate for the patient.