Diagnosis: Obesity
Treatment: Saxenda
The insurer denied: Saxenda
The denial is: Overturned.

The patient is a female being treated for obesity with Saxenda (liraglutide). Per notes from the plan, the medication was denied because it did not meet their established criteria. A letter of support for this appeal was provided by the treating physician. The physician asserts that the patient qualifies for ongoing treatment under a different set of criteria: the patient has completed at least 16 weeks of therapy, the drug is being used in conjunction with a low-calorie diet and exercise plan that will continue for at least 6 months, the patient has a body mass index (BMI) greater than (>) 30, and the patient has comorbid hyperlipidemia. The subject under review is the medical necessity for Saxenda for this patient.

The health plan's determination is overturned.

The requested treatment with Saxenda is medically necessary for this patient. The treating physician provided sufficient attestation to the patient meeting the criteria for ongoing treatment with the medication. There is no proof of a 4% (percent) weight loss, however the patient is receiving a comprehensive weight management plan to include low calorie intake and increase in physical activity, behavioral modification, and continuing follow up for at least six months, in addition to having a BMI over 30. Based on this she qualifies for ongoing treatment consistent with best practices as recommended by current clinical practice guidelines.