Victoza denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza.Findings: Victoza (liraglutide) is a glucagon-like peptide-1 (GLP-1) receptor agonist that, in addition to stimulating insulin release and inhibiting glucagon secretion, slows gastric emptying and increases satiety after eating. Liraglutide has been demonstrated to reduce food intake, promote weight loss, and improve indices of metabolic function in both animal and human studies. A study states that the primary mechanisms associated with these effects are proposed to be due to actions of GLP-1 on peripheral (vagal) and central pathways that affect food intake and metabolism via hindbrain and hypothalamic activation, as well as those brain areas associated with motivation and reward processes.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza for treatment of the enrollee, who has been diagnosed with diabetes type 2. Findings: The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Victoza (liraglutide) is used for weight loss management and to reduce blood sugar in patients with type 2 diabetes mellitus. The available medical studies indicate that Victoza is effective in the treatment of obesity-related risk factors and induces weight loss. From the forms provided, this patient was diagnosed with type 2 diabetes and had a body mass index of 40.88 at the time Victoza was sampled. In general, this medication has been known to lower hemoglobin A1C by about 1% point.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza (liraglutide) injection.Findings: Two of the three physician reviewers found Victoza (liraglutide) injection is not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. Nonalcoholic fatty liver disease (NAFLD) ranges from the more benign condition of nonalcoholic fatty liver (NAFL) to NASH, which is at the more severe end of the spectrum. Weight loss is the primary therapy for most patients with NAFLD because weight loss can lead to improvement in liver biochemical tests, liver histology, serum insulin levels, and quality of life.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza for treatment of the enrollee’s diabetes, type II. Findings: The physician reviewer found that according to the American Diabetes Association as to pharmacologic approaches to glycemic treatment, “A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include efficacy, hypoglycemia risk, impact on weight, potential side effects, cost, and patient preferences.” Per the guidelines for glycemic targets, this patient’s diabetes control is not at goal of hemoglobin A1c 6.5-7%. The patient has tried Victoza and has experienced that this medication is the best treatment option for him. Victoza is a GLP-1 receptor analog, and has a mode of action that is more direct in mimicking the hormone GLP-1, which is deficient in diabetes.

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