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202305-162949

2023

Excellus

PPO

Endocrine/ Metabolic/ Nutritional

Pharmacy/ Prescription Drugs

Medical necessity

Overturned

Case Summary

Diagnosis: Type II Diabetes Mellitus

Treatment: Mounjaro 5 milligram (mg) / 0.5 milliliter (ml) pen injector

The insurer denied coverage for Mounjaro 5 milligram (mg) / 0.5 milliliter (ml) pen injector

The denial is overturned.

This is a patient diagnosed with type II diabetes mellitus (T2DM). This request is for Mounjaro. As reported, the patient tried and failed Ozempic due to persistent nausea with vomiting. The patient has been doing well on Mounjaro; the patient has lost 40 pounds, their headaches and neuropathy have improved and their Hemoglobin A1C was improved from 6.8 % (percent) to 5.5%. The patient started on Mounjaro 5 milligrams (mg). As per the visit note, the patient had been on Ozempic but was unable to tolerate and then switched to Mounjaro 2.5 mg and then Mounjaro 5 mg.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient as the request is medically necessary as described below.

The requested medication Mounjaro (Trizepatide) is a Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1C as well as weight loss (1-3). The patient has already failed one formulary alternative in the form of Ozempic due to side effects. The patient has benefited greatly from the requested medication with a 40-pound weight loss and improvement in their hemoglobin A1C. Continuation of the requested medication is consistent with generally accepted standards of medical practice and is therefore medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Mounjaro 5 milligram (mg) / 0.5 milliliter (ml) pen injector is substantiated.

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