Glucagon-Like Peptide-1 (GLP) 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’s parent has requested authorization and coverage for Wegovy. In this case, the patient presents with metabolic dysfunction-associated steatohepatitis (MASH), with stage 3 (advanced) fibrosis, and is at significant risk for progression to cirrhosis. The patient also has obesity with a body mass index (BMI) greater than the 95th percentile. The patient’s weight is noted to have stabilized, indicating that lifestyle modification alone has not achieved the weight reduction necessary to improve the liver disease. The American Association for the Study of Liver Diseases (AASLD) practice guidance indicates that candidates for Wegovy should have MASH with stage 2-3 fibrosis, which this patient meets with stage 3 fibrosis.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for Zepbound. In November 2023, Zepbound received U.S. Food and Drug Administration (FDA) approval for chronic weight management in patients with a body mass index (BMI) of 27 kg/m2 or greater and weight-related medical conditions. In December 2024, Zepbound received FDA approval for the treatment of patients with obstructive sleep apnea (OSA). Zepbound is the first and only FDA-approved medication for moderate-to-severe OSA. Zepbound’s primary benefit for sleep apnea is through weight loss, which can improve airway function. Clinical studies have shown that Zepbound provides up to 22.5% reduction in baseline weight.

Where the denial was upheld

Findings: The physician reviewer found that a patient has requested authorization and coverage for Wegovy.The records document that this patient presents with a history of metabolic dysfunction-associated steatohepatitis (MASH). Evaluation with a liver biopsy revealed a mild level of fibrosis, and a FibroScan demonstrated no measurable fibrosis, indicating a lack of fibrosis. The patient’s provider has recommended treatment with semaglutide (Wegovy). Currently, the updated guidelines from the American Association for the Study of Liver Diseases (AASLD) recommend the use of Wegovy for the treatment of MASH for patients moderate or advanced fibrosis. Medical literature generally supports semaglutide for individuals with MASH who have moderate to advanced fibrosis. This patient does not meet this requirement, given the documented F1 fibrosis on liver biopsy and F0 fibrosis on FibroScan.

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 the treatment of moderate to severe obstructive sleep apnea (OSA) in patients with a body mass index (BMI) greater than 30 kg/m2. Moderate to severe OSA is defined as having an apnea-hypopnea index (AHI) greater than 15. The FDA’s approval was based on a randomized controlled trial demonstrating an improvement in AHI to less than 15 in patients with moderate to severe OSA and obesity. The authors also noted that patients experienced improvement in hypoxic burden, blood pressure, inflammation, and Epworth Sleepiness Scale. Additional studies have reported on the effects of Zepbound on other obesity-related complications, including heart failure with preserved ejection fraction and diabetes prevention.

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 Glucagon-Like Peptide-1 (GLP), then check the rights and deadlines that apply to your plan.