Polycystic Ovary 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: The patient requested authorization and coverage for an Ozempic pen.The World Health Organization (WHO) defines obesity as an abnormal or excessive fat accumulation that may impair health. Obesity is defined by body mass index (BMI), weight in kilograms divided by the square of height in meters and indicated in adults with a BMI more than 30 kg /m2. Obesity is a major risk factor for noncommunicable diseases such as cardiovascular diseases, diabetes, musculoskeletal disorders, and cancers.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy. Obesity is a multi-causal chronic disease recognized across the lifespan resulting from long-term positive energy balance with the development of excess adiposity that, over time, leads to structural abnormalities, physiological derangements, and functional impairments. The disease of obesity increases the risk of developing other chronic diseases and is associated with premature mortality. According to a study, as with other chronic diseases, obesity is distinguished by multiple phenotypes, clinical presentations, and treatment responses. According to another study, anti-obesity medications, when combined with lifestyle intervention, produce larger weight losses than behavioral treatment alone.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Zepbound auto-injector pen. According to the American Association of Clinical Endocrinologists (AACE) guidelines, patients with overweight or obesity “should be considered for treatment with a weight-loss medication combined with lifestyle therapy when necessary”. The Endocrine Society guidelines have similar recommendations and specifically state that “Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications”.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mounjaro 2.5 mg/0.5 mL subcutaneous pen injector. 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. The records document that this patient does not have type 2 diabetes. Rather, the patient’s hemoglobin A1C was documented to be excellent. The patient has requested treatment with Mounjaro. The U.S. Food and Drug Administration (FDA) has not approved Mounjaro for the treatment of patients with polycystic ovary syndrome (PCOS), abnormal bleeding, or endometrial polyps. The patient is already on an oral contraceptive Nortrel, which should regulate her menstrual cycle and prevent abnormal endometrial growth including polyps.

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