Diagnosis: Obesity.
Treatment: Saxenda 3mg/0.5ml Pen Injector, Pre-service.

The insurer denied the Saxenda 3mg/0.5ml Pen Injector, Pre-service.
The denial is overturned.

The patient is a female with obesity with body mass index of 35.3. The request for Saxenda is under review.

The prior request for Saxenda was denied coverage by the health plan, as the prior request did not include documentation of current enrollment into a qualified comprehensive weight management program for at least 3 months in addition to counseling in a physician's office. The physician is appealing this determination, because this patient has been enrolled in a weight loss program.

Yes, the requested Saxenda is medically necessary.

The prior request for Saxenda was denied as the prior request did not include documentation of current enrollment into a qualified comprehensive weight management program for at least 3 months in addition to counseling in a physician's office. The Endocrine Society guidelines on obesity management recommend the use of Food and Drug administration approved weight loss medications (over no pharmacological therapy) to ameliorate comorbidities and amplify adherence to behavior changes, which may improve physical functioning and allow for greater physical activity in individuals with a BMI (body mass index) 30 or in individuals with a BMI (body mass index) of 27 and at least one associated comorbid medical condition such as hypertension, dyslipidemia, T2DM (type 2 diabetes mellitus), and obstructive sleep apnea.

This patient has a BMI (body mass index) of 35.3. This patient has participated in a weight loss program. In addition, the patient saw her provider recently where diet and activity were discussed. The Endocrine Society guidelines support the use of Saxenda in this clinical situation of a BMI (body mass index) over 30. Without Saxenda, this patient will be at increased risk of the complications of untreated obesity, including type 2 diabetes. Therefore, yes, the proposed Saxenda is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The requested Saxenda was medically necessary and was denied.