Class 3 Obesity denials in California external review
In the California DMHC record, independent physician reviewers decided 18 published external-review cases involving class 3 obesityand overturned the plan’s denial in 94.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for class 3 obesity
| Category | Decisions | Overturned |
|---|---|---|
| Zepbound | 6 | 100% |
| Wegovy Solution Auto-injector | 4 | 100% |
| Wegovy | 4 | 100% |
What the reviewers wrote
Where the denial was overturned
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Zepbound. This patient presents with class 3 obesity, as well as weight-related comorbidities. The U.S. Food and Drug Administration (FDA) has approved Zepbound (tirzepatide) for weight management in patients with obesity (body mass index (BMI) greater than 30 kg/m2) or who are overweight (BMI between 27 and 29.9 kg/m2 with at least one weight-related comorbidity), in addition to a reduced calorie diet and increased physical activity. The FDA approval of Zepbound is supported by medical trials which showed that in adults with obesity or excess weight, treatment with tirzepatide led to substantial and sustained weight loss as compared to treatment with placebo after 52 and 72 weeks.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Zepbound. This patient presents with class 3 obesity, as well as weight-related comorbidities of hyperlipidemia and hypertension. The U.S. Food and Drug Administration (FDA) has approved Zepbound (tirzepatide) for weight management in patients with obesity (body mass index (BMI) greater than 30 kg/m2) or who are overweight (BMI between 27 and 29.9 kg/m2 with at least one weight-related comorbidity), in addition to a reduced calorie diet and increased physical activity. The FDA approval of Zepbound is supported by medical trials which showed that in adults with obesity or excess weight, treatment with tirzepatide led to substantial and sustained weight loss as compared to treatment with placebo after 52 and 72 weeks.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ozempic auto-injector pen. In this case, the patient has a history of class 3 obesity with a current body mass index (BMI) of 50.04 kg/m². He has multiple weight-related comorbidities, including prediabetes, hypertension, and hyperlipidemia. He has started caloric restriction and has been referred to a nutritionist. The U.S. Food and Drug Administration (FDA) approves the use of Ozempic (semaglutide) to lower blood sugar in patients with type 2 diabetes mellitus. Researchers report that clinical research showed that when Ozempic was added to other standard therapies for patients with a history of type 2 diabetes mellitus, these patients saw a substantial decrease in their A1C levels.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving class 3 obesity, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY