Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with impaired fasting glucose, hypothyroidism, hyperlipidemia and obesity. The patients body mass index (BMI) was 36.48 kg/m2. She has been treated with Saxenda in the past for weight loss. The patient was started on a low calorie, high protein diet to facilitate weight loss. The patients BMI was 35.48 kg/m2. The patient was being treated with a trial of Saxenda and high protein diet with intermittent fasting, resulting in a six-pound weight loss. The patient has requested authorization and coverage for Saxenda 18 mg/3 mL. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Saxenda 18 mg/3 mL is medically necessary for the treatment of the patients medical condition. Studies reported, Patients with overweight or obesity and dyslipidemia (elevated triglycerides and reduced high-density lipoprotein cholesterol) should be treated with lifestyle therapy to achieve five to 10% weight loss or more as needed to achieve therapeutic targets. The authors also noted, Medication-assisted weight loss employing phentermine/topiramate ER, liraglutide 3 mg, or orlistat should be considered in patients at risk for future type 2 diabetes mellitus and should be used when needed to achieve 10% weight loss in conjunction with lifestyle therapy. The authors further stated, A generalizable hierarchical algorithm for medication preferences that would be applicable to all patients cannot currently be scientifically justified. Researchers reported, In order to promote long-term weight maintenance, we suggest the use of approved weight loss medication (over no pharmacological therapy) to ameliorate comorbidities and amplify adherence to behavior changes, which may improve physical functioning and allow for greater physical activity in individuals with a BMI greater than or equal to  30 kg/m2 or in individuals with a BMI greater than or equal to  27 kg/m2 and at least one associated comorbid medical condition such as hypertension, dyslipidemia, type 2 diabetes, and obstructive sleep apnea. In this case, the patient has trailed lifestyle interventions but was only able to achieve 2.7% weight loss. The addition of pharmacotherapy can help achieve this goal of 10% weight loss to prevent development of type 2 diabetes mellitus. The patient has been diagnosed with obesity, with a BMI of 35.48 kg/m2, with comorbidities of hyperlipidemia and prediabetes. She is at high risk of developing cardiometabolic complications. The medical evidence supports the requested medication in this clinical setting. Therefore, Saxenda 18 mg/3 mL is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.