Class Iii Obesity denials in California external review
In the California DMHC record, independent physician reviewers decided 19 published external-review cases involving class iii obesityand overturned the plan’s denial in 94.7%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for class iii obesity
What the reviewers wrote
Where the denial was overturned
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Wegovy solution auto-injector.The U.S. Food and Drug Administration (FDA) has approved Wegovy for the treatment of patients with obesity or overweight with one or more related medical conditions. In the STEP 1 randomized controlled trial, 1961 patients with overweight or obesity but without diabetes were treated with either Wegovy or a placebo in addition to lifestyle intervention. The authors found that the mean weight loss was greater in the group treated with Wegovy than in the group treated with a placebo. The STEP 4 trial was a randomized, double-blind, 68-week phase 3 trial of weight maintenance with semaglutide (Wegovy) at 2.4 mg weekly.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for the Zepbound solution auto-injector.The U.S. Food and Drug Administration (FDA) approves tirzepatide, under the brand name Zepbound, for weight management in patients who are overweight, defined as a BMI of 27 kg/m² or greater, with at least one weight-related comorbidity, or who are obese, defined as a BMI of 30 kg/m² or greater. In this case, the records document that the patient has a BMI of over 40 kg/m². The authors reported that treatment with tirzepatide led to substantial, sustained weight loss, with a mean percentage change in body weight at week 72 greater than 20% in subjects on the maximum dosage of 15 mg weekly.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery with Orbera intragastric balloon (CPT 43999). The records provided for review document that this patient has Class III obesity with a body mass index (BMI) of 47.2 kg/m2. The provider has recommended the Orbera intragastric balloon, which is U.S. Food and Drug Administration (FDA) approved for the treatment of obesity in patients with a BMI of 30-40 kg/m2 (Courcoulas, et al.; Vyas, et al.). The Orbera intragastric balloon lacks data supporting its use in patients with a BMI over 40 kg/m2. In addition, the guidelines from the American College of Cardiology (ACC), American Heart Association (AHA), and the Obesity Society do not recommend intragastric balloon therapy for long-term obesity therapy (Jensen, et al.).
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.
Fighting a denial for a GLP-1 drug — Wegovy, Zepbound, Ozempic, Mounjaro, Saxenda? We wrote the full playbook: GLP-1 denial evidence guide.
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 iii 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