Overweight denials in California external review

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 Wegovy solution auto-injector. Wegovy (semaglutide) is a government approved treatment option for weight management. A study comparing semaglutide versus liraglutide found that among adults with overweight or obesity without diabetes, once-weekly subcutaneous semaglutide compared with once-daily subcutaneous liraglutide, added to counseling for diet and physical activity, resulted in significantly greater weight loss. Similarly, in a review of studies exploring the safety and efficacy of five medications currently approved by the government for the treatment of obesity, the authors suggested that semaglutide may have superior efficacy. In this case, the patient is overweight, has hypertension, and has obstructive sleep apnea.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zepbound. The U.S. Food and Drug Administration (FDA) has approved Zepbound for weight management in patients diagnosed with obesity or overweight with at least one weight-related comorbidity such as high blood pressure, type 2 diabetes, or high cholesterol. Overweight is defined as having a BMI greater than 27 kg/m2. One clinical trial evaluated the safety and efficacy of Zepbound for weight loss in patients with obesity or overweight with one weight-related complication. Notably, patients with diabetes were excluded from the study. The authors found that the treatment of patients with Zepbound at various dosages achieved significant weight loss. Another clinical trial evaluated the continued treatment of patients with obesity or overweight with Zepbound.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zepbound. The records indicate that this patient is currently overweight with a BMI of 28 kg/m2. She is requesting Zepbound for weight loss. The U.S. Food and Drug Administration (FDA)-approved tirzepatide (Zepbound) injection for chronic weight management in patients with obesity defined as a body mass index (BMI) of 30 kg/m2 or greater, or overweight with a BMI of 27 kg/m2 or greater with at least one weight-related condition, to be taken in addition to a reduced calorie diet and increased physical activity. Glucagon-like peptide receptor agonists (GLP-1 RAs) have repeatedly shown promising results in the reduction of body weight in obese patients with and without diabetes.

Findings: The physician reviewer found that the patient has requested authorization and coverage for Wegovy solution auto-injector. The U.S. Food and Drug Administration (FDA) has approved Wegovy for chronic weight management in patients diagnosed with obesity or overweight and one weight-related condition. Overweight is defined as having a body mass index (BMI) greater than or equal to 27 kg/m2. Wegovy is to be used as an adjunct to dietary changes and physical activity. In the STEP 1 clinical trial, patients with obesity or overweight and more than one weight-related condition were treated with either Wegovy or placebo in addition to lifestyle intervention. The authors found that weight loss in patients who were treated with Wegovy was greater than in those who were treated with placebo.

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 overweight, then check the rights and deadlines that apply to your plan.