Insulin Resistance: when insurers say no, reviewers often say yes
In 14 published external-review decisions involving insulin resistance, independent physician reviewers overturned the insurer’s denial 100% of the time.
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% |
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 outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for insulin resistance was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY