PRIOR AUTHORIZATION OBESITY PHARMACOTHERAPY TEMPLATE
Date: Enter Date Regarding: Patient Name To whom it may concern,
I am writing on behalf of my patient Patient Name to appeal the denial of coverage of: 1) Qsymia( phentermine / topiramate), 2) Saxenda( liraglutide), 3) Wegovy( semaglutide), 4) Mounjaro( Tirzepitide) for the treatment of childhood obesity. Medication is FDA- approved for treatment of obesity in children 12 years and older defined as an initial body mass index( BMI) at the 95th percentile or greater standardized for age and sex. Patient Name is XXX years old and his / her BMI is at the XXX percentile, thus meets FDA criteria for treatment with this medication. Furthermore, Patient Name’ s BMI is more than 20 % greater than the 95th percentile, thus meeting criteria for severe obesity, which is associated with greater risk of hypertension, dyslipidemia, metabolic dysfunction associated liver disease, obstructive sleep apnea, prediabetes and subclinical atherosclerosis. Name already has the following comorbidities of: List comorbidities 1) impaired fasting glucose with a fasting blood glucose greater between 100 and 126 mg / dL and a hemoglobin A1c between 5.7 and 6.4 %, 2) nonalcoholic fatty liver disease, 3) hypertension, 4) polycystic ovarian syndrome, 5) obstructive sleep apnea. All of these complications are directly linked with increased morbidity and premature mortality in this population.
In January of 2023, the American Academy of Pediatrics released their clinical practice guidelines recommending the use of weight reducing pharmacotherapy for youth ages 12 and older with Class II or III obesity( 1). Untreated adolescent obesity has a high rate of tracking into adulthood with its antecedent cardiometabolic complications. The disease of obesity severely affects patients’ quality of life both physically and psychosocially. Data suggests that treatment of adolescent obesity is economically beneficial to the individual and the society as it saves long term costs of treatment of obesity complications. There are currently, multiple FDA approved medications for the indication of severe obesity in youth. These will be used under my supervision and regular monitoring.
GLP-1 Receptor Agonists: Two FDA-approved GLP-1RA are available for use in youth ages 12 and older with obesity; liraglutide 3 mg daily( Saxenda) and semaglutide 2.4 mg weekly( Wegovy). Clinical studies in the pediatric population demonstrated significant reduction in body weight with both medications.( 2,3). While semaglutide 2.4 mg once weekly demonstrated improvement in cardiometabolic factors( hemoglobin A1c, lipids, transaminases), once daily liraglutide did not show a difference in these factors compared to placebo. Given advantages in efficacy and better adherence to once weekly medication I am specifically requesting approval of coverage of Wegovy for Name.
Phentermine monotherapy: Phentermine is approved in the United States for adolescents > 16 years with severe obesity for a duration of up to 12 weeks. Phentermine acts on appetite control centers in the hypothalamus; clinical studies have demonstrated efficacy in weight reduction in adolescents in limited trials( 4).
53