Meets criteria

All qualifying criteria satisfied

Every criterion in the payer's coverage policy is met and supported by the clinical record — sufficient to deem the requested therapy medically necessary.

All criteria confirmed

BlueCross BlueShield Anthem

Request for coverage of Wegovy — Case ID CASE-178

Dear Reviewer,

We are requesting coverage of the therapy above. The record below shows the patient meets the plan's medical necessity criteria for this indication.

Respectfully submitted on behalf of the treating provider.

Qualifying criteria

all confirmed

Each policy criterion is shown with the supporting finding from the record.

01Prior supervised lifestyle program was unsuccessful

Confirmed

FindingClinical note documents a provider-supervised 6-month lifestyle program (Jan–Jun 2024) with less than 5% weight loss. Clinical note · p.2

02Patient is 18 years of age or older

Confirmed

FindingRecord confirms the patient is over 18.

03BMI meets the policy threshold, documented recently

Confirmed

FindingBMI is above the policy threshold and documented within the required 60-day window.

04Requested for chronic weight management

Confirmed

FindingFor chronic weight management, not treatment of type 2 diabetes.

05No relevant contraindications

Confirmed

FindingNo history of medullary thyroid carcinoma, MEN 2, or pancreatitis.

06Counseled on risks, benefits, and adherence

Confirmed

FindingProvider counseled the patient on risks, benefits, and long-term adherence.