Semaglutide 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. A review noted that “Glucagon-like peptide-1 (GLP-1) receptor agonists are a class of antidiabetic medications that have shown promise in encouraging glycemic control and promoting weight loss in patients with or without type 2 diabetes”. The authors summarized and discussed the weight loss results from clinical trial programs. The authors noted that all three clinical trials demonstrated that semaglutide has superior efficacy compared with placebo and other antidiabetic medications in weight reduction, which led to the U.S. Food and Drug Administration (FDA) approval of semaglutide (Wegovy) for weight loss. Semaglutide was FDA-approved for diabetes type 2 treatment under the name Ozempic in 2017 and for weight management under the name Wegovy in 2021.

Where the denial was upheld

Findings: The physician reviewer found that the patient has requested authorization and coverage for Wegovy. The obesity management guidelines from the American Association of Clinical Endocrinologists (AACE) emphasize 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 disease among other chronic conditions”. The AACE noted that pharmacotherapy for weight loss could be used for patients with a BMI of 30 kg/m2 or greater or a BMI of 27 kg/m2 or greater with adiposity-related complications in conjunction with medical nutrition therapy, physical activity, and psychological interventions.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy. 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 body mass index (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 Semaglutide, then check the rights and deadlines that apply to your plan.