Diagnosis: Type II Diabetes Mellitus
Treatment: Mounjaro
The insurer denied the request for Mounjaro.
The health plan's determination is overturned.

The patient is a male with type 2 diabetes and chronic kidney disease. He was intolerant to Ozempic (diarrhea), Trulicity (diarrhea), Metformin (diarrhea), and Rybelsus (diarrhea). His hemoglobin A1C (hgbA1C) was 7.7 percent (%). The request for continuation of Mounjaro is under review.

No, the health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient. The patient has experienced intolerance to two of the formulary alternatives as supported by submitted clinical documentation. The requested Mounjaro was denied, but it is medically necessary.

The requested Mounjaro is medically necessary for this patient. This request is for Mounjaro for the treatment of type two diabetes. The formulary alternatives are Ozempic, Trulicity, and Victoza. The appeal documentation includes progress notes indicating the patient was not able to tolerate Ozempic or Trulicity due to gastrointestinal side effects. The submitted progress notes also indicate that the patient is doing well on Mounjaro without side effects. The patient is at a high risk of also being intolerant to Victoza, the remaining formulary alternative, given Victoza is in the same drug class as Ozempic and Trulicity. Without Mounjaro, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy.

The health plan's determination of medical necessity is overturned in whole.