Diagnosis: Polycystic ovarian syndrome (PCOS).
Treatment: Victoza 0.6 mg/0.1 ml, quantity per 72 days

The insurer denied coverage for Victoza 0.6 mg/0.1 ml, quantity per 72 days. The denial is upheld.

This patient is a female with a history of polycystic ovarian syndrome (PCOS). Initially, the patient was treated with Metformin and Spironolactone; there was no indication of the patient's response to these medications. The patient was noted to have elevated testosterone levels, but there was no mention of glucose levels, insulin levels, Hemoglobin A1c, or gonadotropins. The medical record mentioned that the patient had hirsutism. The patient was noted to have started on Victoza (liraglutide) 0.6 mg daily, and her weight decreased from a body mass index (BMI) of 30.8 to a BMI of 28.5. It was stated that her insulin sensitivity increased and the patient lost a significant amount of body weight.

As per UpToDate, the limited data in women with PCOS on liraglutide states, "Though not specifically approved for PCOS, liraglutide is approved for individuals with a BMI of 30 kg/m2 or greater." While there is support for liraglutide medication use for weight loss for individuals with a BMI of 30 kg/m2 or greater, there is lack of literature evidence to support that this medication increases insulin sensitivity and is medically indicated for patients with PCOS below the threshold BMI of 30 kg/m2.

Based on the review of the medical records provided, there is lack of objective clinical data for review, such as the patient's weight changes or the effects of the medication use on the patient's lab values, such as glucose levels, insulin levels, Hemoglobin A1c, or gonadotropins. This lack of data accompanying the patient's records, and the fact that the patient's BMI is now down to 28.5 (below the threshold BMI of 30 kg/m2 for liraglutide use), the continuation of liraglutide (Victoza) as currently prescribed is not medically necessary to treat this patient's medical condition.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the preservice request for Victoza 0.6 mg/0.1 ml, quantity per 72 days is upheld. The medical necessity is not substantiated.