Diagnosis: Obesity.
Treatment: Saxenda 3mg/0.5ml Pen Injector.
The insurer denied the Saxenda 3mg/0.5ml Pen Injector.
The denial is overturned.

The patient is a female with metabolic syndrome, polycystic ovarian syndrome, obesity, and a history of gestational diabetes. The request for Saxenda is under review. The prior request for Saxenda was denied as the first request did not include submitted documentation that the patient has been enrolled in a qualified complete weight management program for at least three months, with proof of current and prior enrollment and at least monthly participation. The attending physician is appealing this determination because the patient has been attending her gym and Weight Watchers program several days per week since the delivery of her son. She has also tried and failed metformin, phentermine, Topamax, and Victoza. Her body mass index is 37.51 kg/m2 (kilograms per meters squared).


Yes, the requested Saxenda is medically necessary.
This patient is obese with a body mass index of 37.51 kg/m2 (kilograms per meters squared). This is complicated by metabolic syndrome and polycystic ovarian syndrome. The prior request for Saxenda was denied as the first request did not include documentation that the patient has been enrolled in a qualified complete weight management program such as Weight Watcher or Curves Complete for at least 3 months, with proof of current and prior enrollment and at least monthly participation. The appeal letter indicates that the patient has been actively enrolled in Weight Watchers. The appeal letter indicates that the patient has been attending her gym and Weight Watchers program several days per week. The use of Saxenda in this clinical situation is supported by the Endocrine Society guidelines on the management of obesity. Without Saxenda, this patient will be at risk of further complications of untreated obesity, including type 2 diabetes. This patient is at particular risk of type 2 diabetes as she has a history of gestational diabetes. Therefore, the requested Saxenda is medically necessary.

The requested Saxenda is medically necessary as outlined above, and it was previously denied.