Polycystic Ovarian Syndrome 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 reimbursement and prospective authorization and coverage for Zepbound. The submitted documentation supports the medical necessity of the requested medication. The U.S. Food and Drug Administration (FDA) approves the use of Zepbound (tirzepatide) injection for chronic weight management in adults with obesity, defined as a BMI of 30 kg/m² or greater, or who are overweight, defined as a body mass index (BMI) of 27 kg/m² or greater, with at least one weight-related condition such as high blood pressure, type 2 diabetes, or high cholesterol for use in addition to a reduced calorie diet and increased physical activity. Anti-obesity medications, when combined with lifestyle intervention, produce larger weight losses than behavioral treatment alone.

Findings: The physician reviewer found that an enrollee has requested authorization and coverage for Ozempic. Obesity is a disease associated with a significant increase in mortality and many health risks, including type 2 diabetes mellitus, hypertension, dyslipidemia, and coronary heart disease. Weight loss in patients with obesity is associated with a reduction in mortality. The American Association of Clinical Endocrinologists (AACE) guidelines for the medical care of patients with obesity report that patients with obesity should be considered for treatment with weight-loss medication combined with lifestyle therapy when necessary to achieve sufficient improvements in lipids such as elevated triglycerides and reduced high-density lipoprotein (HDL-C).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oophorectomy of the left ovary and fertility/infertility testing. The records provided for review document that this patient presents with a diagnosis of polycystic ovarian syndrome (PCOS) and obesity. Per the provider, the patient’s abnormal bleeding is related to her diagnosis of PCOS. In this clinical setting, the patient should be treated with weight loss and hormonal management. The patient does not have any pelvic pathology to support an indication for surgery and there is no indication for an oophorectomy. In the medical literature, one study noted that if cysts do not resolve and they “pose the risk of ovary torsion, they need to be removed by surgical intervention.” This patient’s records do not report concern for ovary torsion.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rybelsus. The American Association of Clinical Endocrinologists (AACE) emphasized the fact that “excessive adiposity can become dysfunctional and predispose the individual to the development of many medical complications including diabetes mellitus and non-alcoholic fatty liver, in addition, it does support the medical therapy of obesity as it increases the risk of multiple chronic diseases. Pharmacotherapy is recommended for weight loss for patients with a BMI of 30 kg/m2 or greater, or a BMI of 27 kg/m2 or greater with adiposity-related complications, to be taken in conjunction with medical nutrition therapy, physical activity, and psychological interventions.

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 polycystic ovarian syndrome, then check the rights and deadlines that apply to your plan.