Overweight Obesity Oth 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 Zepbound. The U.S. Food and Drug Administration (FDA) has approved Zepbound for chronic weight management in patients with obesity or overweight with at least one weight-related condition. Obesity is defined as having a body mass index (BMI) of 30 kg/m2 or greater and overweight is defined as having a BMI of 27 kg/m2 or greater. Zepbound should be taken in addition to a reduced calorie diet and increased physical activity. When combined with lifestyle intervention, weight loss medication results in greater weight loss than behavioral treatment alone. Patient-driven, goal-oriented behavioral and physical activities are recognized as valid components of lifestyle modification.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Zepbound. The U.S. Food and Drug Administration (FDA) has approved Zepbound for chronic weight management in patients with an initial body mass index of 30 kg/m2 or greater (obesity), or patients with a body mass index of 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition. Zepbound is indicated for chronic weight management and is intended for long-term use. Clinical studies confirm that Zepbound is superior to other weight loss pharmacotherapy options and lifestyle therapies for both weight loss and weight-related comorbidity management.

Where the denial was upheld

Findings: The physician reviewer found that a patient has requested authorization and coverage for Wegovy. Clinical practice guidelines support the use of pharmacotherapy for the treatment of obesity, as it increases the risk of developing multiple chronic diseases. Pharmacotherapy for weight loss is recommended for patients with a body mass index (BMI) greater than or equal to 30 kg/m2, or a BMI greater than or equal to 27 kg/m2 with adiposity‑related complications, in conjunction with medical nutrition therapy, physical activity, and psychological interventions. In this case, the patient’s BMI is significantly less than 30 kg/m2 and therefore pharmacotherapy is not recommended.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Wegovy. In this case, the patient has obesity with a documented body mass index of 34.91 kg/m².The records reflect participation in comprehensive lifestyle modification efforts, including dietary calorie restriction and exercise. The patient has received treatment with Wegovy for approximately two years. However, the records document diminished therapeutic effectiveness over the past year, including weight gain despite continued treatment.Current medical literature supports continuation of anti-obesity pharmacotherapy when clinically meaningful weight loss or maintenance of therapeutic benefit is demonstrated.

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