Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity

Treatment: Wegovy 0.5 milligram (mg) pen injector

The insurer denied coverage for Wegovy 0.5 milligram (mg) pen injector (pre-service)

The denial is overturned.

The patient is an adult female with a medical diagnosis of obesity and hypertension. Per the treating provider's notes, the patient joined the Sequence program one year ago with a body mass index (BMI) of 34 kilograms per meter squared (kg/m2), height of five feet two inches (5'2"), and a weight of 185 pounds (lbs). She has had access and support to nutrition and fitness professionals, in addition to regular monitoring by their clinician on their weight loss.

Since starting the Sequence program, the patient has seen improvements in their health and has a current BMI of 28 and current weight of 154 lbs. 

Wegovy 0.5 milligram (mg) pen injector (pre-service) is considered medically necessary for this patient. The usage of the requested drug is also supported by current peer reviewed literature. The claimant is obese with the latest BMI of 28 which along with hypertension is consistent with the Food and Drug Administration (FDA) approved indications for Wegovy. Wegovy is more effective than other medications and can help achieve 12%-20% (percent) total body weight loss.

"INDICATIONS AND USAGE
WEGOVY is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of
1) 30 kg/m2 or greater (obesity) or
2) 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia). (1)

Limitations of Use:
3) WEGOVY should not be used in combination with other semaglutide-containing products or any other GLP-1 receptor agonist (1).
4) The safety and efficacy of coadministration with other products for weight loss have not been established (1).
5) WEGOVY has not been studied in patients with a history of pancreatitis (1)." (Wegovy Package Insert).

"The conclusion was in participants with overweight or obesity, 2.4 mg of semaglutide once weekly plus lifestyle intervention was associated with sustained, clinically relevant reduction in body weight." (Wilding et al., 2021).

"The primary goal of pharmacotherapies like semaglutide for chronic WM (weight management) is to achieve a clinically meaningful WL when combined with lifestyle intervention and to provide longterm WM and to minimize weight regain. More importantly, semaglutide, through both direct and indirect actions, is hoped to meaningfully impact obesity related comorbidities. Average WL (weight loss) of 10% to 15% has been shown to significantly alleviate many complications associated with obesity, including diabetes, hypertension, osteoarthritis, and gastroesophageal reflex disease. The benefits of WL have also been demonstrated in dyslipidemia, nonalcoholic fatty liver disease, sleep apnea, and stress incontinence." (Kushner, R. F., et al., 2020).    

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Wegovy 0.5 milligram (mg) pen injector (pre-service) services is substantiated.