Pre-diabetes denials in California external review
In the California DMHC record, independent physician reviewers decided 88 published external-review cases involving pre-diabetesand overturned the plan’s denial in 68.2%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for pre-diabetes
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. | 80 | 68.8% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 8 | 62.5% |
What the reviewers wrote
Where the denial was overturned
Findings: The physician reviewer found that the patient has requested authorization and coverage for Wegovy. Obesity is a chronic disease, medication-assisted weight loss should be considered in patients at risk for future type 2 diabetes mellitus, and medication should be used when needed to achieve 10% weight loss in conjunction with lifestyle therapy. Obesity is defined as an “abnormal or excessive fat accumulation that may impair health”. Obesity is defined by BMI, weight in kilograms divided by the square of height in meters, in adults over 30 kg /m2.
Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for an Ozempic pen. Obesity is a risk factor for prediabetes and type 2 diabetes. Clinical trials testing lifestyle modification in conjunction with anti-obesity medication have demonstrated that weight loss can restore normoglycemia in those with prediabetes. Prediabetes and type 2 diabetes are associated with an increased risk of cardiovascular disease and related adverse events. In individuals with prediabetes, weight loss and prevention of diabetes are accompanied by improvements in cardiometabolic risk factors such as blood pressure, waist circumference, triglycerides, and high-density lipoprotein (HDL) cholesterol. In addition, these improvements have been shown to be maintained long-term. The U.S.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rybelsus tablet 14 mg. Prediabetes is a precursor to type 2 diabetes, a disease highly associated with microvascular and macrovascular disease. Patients with prediabetes have a higher average sugar than normal but not as high as those with diabetes. For patients with prediabetes, the American Association of Clinical Endocrinology (AACE) recommends lifestyle changes. Medications for obesity are recommended for patients with a body mass index (BMI) over 27 kg/m2 such as phentermine/topiramate ER, liraglutide, or weekly semaglutide.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ozempic. The U.S. Food and Drug Administration (FDA) approved the use of Ozempic, known generically as semaglutide, for lowering blood sugar in patients with type 2 diabetes mellitus based on the results from a clinical research program that included 8,000 patients, all with a history of type 2 diabetes mellitus, that showed a substantial decrease in hemoglobin (Hb) A1C levels when Ozempic was added to other standard therapies. Non-diabetic patients were excluded from the research trial. While the trial also showed evidence of weight loss in patients with type 2 diabetes on Ozempic, the FDA does not approve the use of Ozempic for weight loss.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 pre-diabetes, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY