Diagnosis: Prediabetes.
Treatment: Ozempic.

The insurer denied the Ozempic.
The denial is upheld.

The patient is a female with prediabetes. Denial of Ozempic is being appealed. The patient started the medication approximately four months ago. The request was denied because the patient does not have type 2 diabetes. The provider notes that the patient has low iron and B vitamins that will become further depleted with metformin.

No, the treatment with Ozempic is not medically necessary.

Ozempic is FDA (United States Food and Drug Administration)-approved as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. This patient has a diagnosis of prediabetes. Provider notes that metformin is contraindicated due to history of low iron and B vitamins. Metformin is contraindicated in patients with severe renal dysfunction. It is not contraindicated with low iron and B vitamins. There is no evidence of trial and failure.

Medically necessary services are those which are:
1) safe
2) effective
3) generally accepted national standard of medical practice
4) not provided primarily for convenience of the patient or the practitioner
5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested Ozempic is not medically necessary, because it is not in accordance with generally accepted national standard of medical practice for treatment of prediabetes.

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