Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied coverage for Wegovy.
The denial is overturned.

According to the documentation submitted, this is an adult with a history of obesity. The patient presented to the nurse practitioner's office for a weight loss program consultation. Body Mass Index (BMI) was 33.6. The patient was started on a semaglutide 12 week program. 

The insurer has denied coverage for Wegovy, as not medically necessary. In a Final Adverse Determination letter, they stated that BMI (Body Mass Index) must be at least 30 and the patient must be enrolled in a qualified weight management program for at least 3 months. There must be proof of enrollment. The patient must have counseling and monitoring from the doctor's office. The requested medication is denied based on Pharmacy Management Drug Policy for Anorexiants; Contrave (naltrexone/bupropion ER), QysmiaTM (phentermine/topiramate ER), Saxenda (liraglutide), Wegovy (semaglutide) and Xenical (orlistat), Imcivree (setmelanotide) (Pharmacy-03). 

The patient is appealing. In an appeal letter, the Family Medicine physician stated that the patient has been receiving weight management services and counseling with a healthcare provider for over three months. The patient was started on Wegovy. The patient had a positive response with gradual weight loss.

The patient has been in a weight loss program. The patient has a Body Mass Index (BMI) of 33.6. The patient has tried diet and exercise. The patient also has hypothyroidism. The patient started Wegovy and has had a gradual weight loss. The physician is requesting to continue treatment with Wegovy. 

Up To Date has an article titled "Obesity in Adults: Drug Therapy." The article states that a number of medications are approved by the U.S. Food and Drug Administration (FDA) for the treatment of obesity in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those with a BMI over 30 or a BMI (Body Mass Index) over 27 with related comorbidities. Semaglutide is a GLP-1 agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction, as well as improvement in glycemia and lipids. It has also demonstrated cardiovascular benefits. 

An article in JAMA is titled "Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity." 803 participants in this study were randomized to either continue Semaglutide or to take a placebo after 20 weeks of semaglutide treatment. Those who continued the treatment with semaglutide had ongoing weight loss, a better lipid profile, improved glucose metabolism, better blood pressure control, and physical functioning scores. The group who took the placebo regained their weight. The article states that the result of this study emphasizes the chronicity of obesity and the need for treatments that can maintain and maximize weight loss. 

This patient has a BMI (Body Mass Index) over 30. Wegovy is an FDA (Food and Drug Administration) approved treatment for obesity in patients with a BMI over 30. The medical literature supports the beneficial effects of semaglutides in achieving weight loss in obese patients. It is a medically necessary treatment. 

Based on the above, the insurer's denial must be reversed. 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 is substantiated.