Diagnosis: Obesity.
Treatment: Wegovy.
The insurer denied coverage for Wegovy.
The denial is overturned.

This is a patient diagnosed with Obesity. This request is for Wegovy. As reported the patient suffers from dyslipidemia and non-alcoholic fatty liver disease. The patient has tried the weight loss program Noom with no success. The patient also owns a Peloton bike and exercises 4-5 times per week. The patient was able to bring their weight 185 pounds (lbs). Most recently, the patient's weight was 216 lbs with a body mass index (BMI) of 33.83. The patient had a Hemoglobin A1C (HgbA1C) of 5.1%. The patient's provider has requested Wegovy to aid in weight loss.

Semaglutide is a Glucagon-like peptide-1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity (2-4). Recent studies published in major peer reviewed medical journals have shown safety and efficacy of Semaglutide for the treatment of obesity (5-7). This medication is now available for the treatment of obesity in the form of Wegovy. The standard of care requires that the patient is participating in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and/or hyperlipidemia. The patient has a BMI of 33.83 and is participating in lifestyle modification such as the weight loss program, Noom and exercising on their bike 4-5 times per week. The request meets the standard of care and is 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 Wegovy is substantiated.