Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy.
The determination is upheld.

The patient is a female a with past medical history of obesity, pre-diabetes, hyperlipidemia, and iron deficiency anemia. The patient had an office visit with her primary care physician (or provider) (PCP) noting blood pressure 148/94, body mass index (BMI) 38.22, and hemoglobin A1c of 5.8. Office notes state the patient declined a glucagon-like peptide (GLP) 1 agonist and was referred to a nutritionist. On the same date, the patient was seen by cardiology due to palpitations occurring once every 1-2 months that lasted a few seconds. It was recommended the patient wear a 4 day cardiac monitor but the patient declined. The provider recommended a heart healthy diet and regular aerobic exercise and the patient was scheduled to return for a stress echocardiogram.
The insurer sent a denial letter for coverage of Wegovy stating the request was denied because they did not see what they needed to approve the drug Wegovy.  A summary report of Peloton use showed the patient exercised between 40-170 minutes per week. There is documentation of meal delivery, 8-10 meals per week. The insurer sent a final adverse determination continuing to deny coverage for Wegovy with the denial stating an appeal was requested because the patient's doctor felt the medication was medically necessary for the patient's condition. The denial stated they did not see that the patient had attempted weight loss through a comprehensive lifestyle program which included reducing caloric intake by about 30% (percent), completing or working up to completing 150 minutes of exercise per week and unable to achieve a 5% weight reduction, exercise goals and behavior therapy for at least 6 months prior to request for drug therapy. The patient's provider appealed the denial decision and the patient appealed denial decision. At issue is the medical necessity of Wegovy.

The Wegovy is not medically necessary. Per updated guidelines for the treatment of obesity "The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of diet, exercise, and behavioral modification. All patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. The behavioral modification component facilitates adherence to diet and exercise regimens, and includes regular self-monitoring of food intake, physical activity, and weight". Although the patient has participated in exercise over a period of several months she did not demonstrate a routine of exercise but rather sporadic episodes of exercise which would not likely contribute to weight loss. There was no documentation that the patient could not participate in an exercise program of at least 150 hours/week. In addition, there is no specific documentation of dietary change to reduce caloric intake on a daily basis over a period of several months. In summary, the patient did not adhere to diet and exercise regimen over a several month period of time, nor have unsuccessful weight loss while adhering to diet and exercise regimen and therefore, Wegovy is not medically necessary for the patient.