Diagnosis: Metabolic syndrome

Treatment Saxenda 3 milligram (mg)/0.5 milliliter (mL) pen injectors

The insurer denied coverage for Saxenda 3 milligram (mg)/0.5 milliliter (mL) pen injectors.

The denial is upheld.

This is a female with medical history of metabolic syndrome, hyperlipidemia, hypothyroidism, asthma and GERD (gastroesophageal reflux disease). The patient was seen by her Gynecology specialist for supervised weight loss. The patient was 214 pounds (BMI [body mass index] 34). The patient was put on weight loss program with caloric restriction. Her weight came down to 164 pounds [lb]. Later, the patient was put on Phentermine and her weight decreased to 146lb. Phentermine was discontinued when her weight was 185 lb. She was put on Qsymia, but patient had side effect of decrease mental acuity, her weight went up to 201lb. When she was started on Saxenda she lost only 7lb. Her doctor wants to continue her on Saxenda, but her insurance denied the request indicating that the patient has not demonstrated at least 5% (percent) weight loss in 5 months of therapy.

Based on above data, the patient had clear benefit from low caloric diet, she lost 50lb (214 down to 164lb) approximately 23% weight loss, and then on Phentermine 10.9%, reduction in weight, while 6 months on saxenda only 3% weight loss. Studies showing that 5% to 10% reduction in weight have important health benefits (Reference 1), of patient not losing at least 5% of body weight after 3 to 6 months of therapy, the treatment should be switched to another anti-obesity medication. (Reference 1) Saxenda (liraglutide) 3mg (milligram) can be used in non-diabetics for weight loss (reference 2, 3), but it appears that this patient has not achieved the expected 5 % weight loss in 5 months.

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

The insurer's denial of coverage for Saxenda 3 milligram (mg)/0.5 milliliter (mL) pen injectors is upheld. Medical Necessity is not substantiated.