Diagnosis: Obesity Treatment: Wegovy The insurer denied the Wegovy. The determination is overturned. The patient has a history of obesity and is requesting continuation of coverage for semaglutide injections (Wegovy). According to information provided in the Prior Authorization request, the patient's baseline starting weight was 174 pounds and her present weight on treatment was 141 pounds. The plan's criteria for the continuation of semaglutide (Wegovy) include at least a 5 percent reduction from baseline body weight and the maintenance of the initial 5 percent reduction. At issue is the medical necessity of Wegovy. The requested health service/treatment of Wegovy was medically necessary for this patient. In this case, the patient has lost 33 pounds, which is a 19% reduction. Therefore, the patient meets the criteria for continuing Wegovy. Wegovy is now considered to be one of the most effective and safe treatments for obesity. It is considered the standard of care in obese and/or overweight patients with weight-related comorbidities who have not reached weight loss goals with behavioral modification.

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