Insulin Resistance denials in California external review
In the California DMHC record, independent physician reviewers decided 14 published external-review cases involving insulin resistanceand overturned the plan’s denial in 100%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for insulin resistance
| Category | Decisions | Overturned |
|---|---|---|
| Ozempic | 8 | 100% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 9 | 100% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 5 | 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.In this case, the patient has a history of hyperlipidemia, insulin resistance, and obesity. The patient’s provider has recommended treatment with Zepbound. The U.S. Food and Drug Administration (FDA) approved tirzepatide (Zepbound) for weight management in patients with obesity defined as a BMI of 30 kg/m2 or greater, or overweight with a BMI of 27 kg/m2 or greater, and at least one comorbidity related to being overweight. The Surmount-1 trial was a phase 3, multicenter, double-blinded, placebo-controlled trial assessing over 2,500 patients with obesity or who were overweight with one or more weight-related comorbidities who were prescribed different dosages of Zepbound or placebo.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Mounjaro Solution Pen-Injector. This patient presents with a history of history of type 1 diabetes with hyperglycemia, which was later amended to type 2 diabetes, insulin resistance, and morbid obesity. The patient has been treated with glucagon, lisinopril, and Humulin, with use of Freestyle Libre 2 Sensor. Per the provider, the patient has severe insulin resistance. The patient has been treated with Mounjaro. As noted in the medical literature, Mounjaro is indicated as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus. Mounjaro is a subcutaneously-administered, once-weekly, dual agonist of glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptors.
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 insulin resistance, 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