Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity.

Treatment: Ozempic.

The insurer denied coverage for Ozempic.

The denial is upheld. 

This is a male patient with diagnoses of male hypogonadism, hypothyroidism due to Hashimoto thyroiditis, prediabetes, and obesity. The patient had a Telemedicine visit.  As per the video visit notes, the patient presented for follow up of hypogonadism, hypothyroidism, obesity, pre-diabetes mellitus (preDM); and also with psoriasis and psoriatic arthritis.  Bariatric surgery was discussed previously but the patient was reportedly not interested.  The provider is requesting authorization for Ozempic.  

As per Bessesen et al. (2018), "These [anti-obesity] drugs vary in their efficacy and side-effect profiles but all provide greater weight loss than do lifestyle changes alone.  Even though obesity is widespread and associated with adverse health consequences, and anti-obesity drugs can help people to lose weight, very few patients use these drugs partly because of concerns about safety and efficacy, but also because of inadequate health insurance coverage.  Despite great advances in our understanding of the biology of weight regulation, many clinicians still believe that patients with obesity should have the willpower to eat less.  The tendency to hold the patient with obesity responsible for their condition can be a barrier to greater acceptance of anti-obesity drugs as appropriate options for treatment.  Physicians should be comfortable discussing the risks and benefits of these drugs, and health insurance companies should provide reasonable coverage for their use in patients who are most likely to benefit.  Although few promising anti-obesity medications are in the drug-development pipeline, the most promising drugs are novel molecules that are co-agonists for multiple gut hormones..."

As per Aroda et al. (2019), "Guidelines recommend treatment goals targeting HbA1c [Hemoglobin A1C], body weight, blood pressure, and low-density lipoprotein cholesterol.  Development of new treatments for type 2 diabetes requires an understanding of their mechanism and efficacy, as well as their relative effects compared to other treatment choices, plus demonstration of cardiovascular safety. Subcutaneous semaglutide is a glucagon-like peptide-1 receptor agonist currently approved in several countries for once-weekly treatment of type 2 diabetes." 

Drug therapy is often a helpful component in the treatment regimen for people with obesity; it can be considered for those with a body mass index (BMI) >30, or a BMI of 27 to 29.9 with weight-related comorbidities, who have not met weight loss goals (loss of at least 5 percent of total body weight at three to six months) with a comprehensive lifestyle intervention. The choice of anti-obesity drug depends upon patient comorbidities but also takes into account patient preferences, adverse effects, and insurance coverage. For most patients, liraglutide is preferred first-line pharmacotherapy.  If there is an inadequate response to liraglutide or it is not tolerated, and treatment with a different drug is considered, the recommendation is to switch to orlistat, although side effects often limit its use.  Phentermine (as a single agent) is also an effective, inexpensive, and widely prescribed option. 

Ozempic is not considered medically necessary for this patient as he does not have a diagnosis of type 2 diabetes and this drug is being prescribed by his Primary Care Physician (PCP) for obesity management.  Ozempic is being researched for obesity but this is subject to Food and Drug Administration (FDA) approval. 

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.      

The insurer's denial of coverage for Ozempic should be upheld.