Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Contrave. The Health Plan has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees weight gain and hypothyroidism.Findings: The documentation provided does not support the medical necessity for the medication at issue in this patients case. The medication Contrave is not proven to be safe in a patient with this medical history and concomitant use of dextroamphetamine. Contrave is a combination of naltrexone, an opioid antagonist and bupropion, an aminoketone antidepressant. This medication is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight related comorbidity (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia).  The medical literature recommends that antiobesity medications should be considered only for patients who have not achieved weight loss goals with diet and lifestyle changes, and after an extensive discussion of the risks and benefits. This patient is overweight but she is still under the recommended criteria with a BMI of 27 kg/m2  and with comorbidities at which pharmacological treatment for obesity is indicated. According to medical practice guidelines and U.S. Food Drug and Administration (FDA) approved guidelines for the use of Contrave, the treatment is approved only for patients with BMI at or over 27 kg/m2  with comorbidities. The Endocrine Societies guidelines rule against the use of antiobesity medications outside the FDA approval indications. Per FDA guidelines, the medication is contraindicated in patients with anorexia nervosa and the label has warnings about increased risk for suicide in patients with depression. The records indicate that this patient has a history of emotional issues, anorexia nervosa and possibly a body dysmorphic disorder. The provider states that this patient has done well in the past with Wellbutrin and part of her rationale in prescribing Contrave was to help with her emotional issues. However, this is not an indication for Contrave. The patient is also on Adderal (dextroamphetamine) which is an amphetamine derivative for attention deficit disorder. Studies have shown that naltrexone, an active ingredient of Contrave would decrease the effect of amphetamine, so there is a potential for interaction with Adderall. For the reasons noted above, Contrave was not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified 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.