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Semaglutide prior authorization for weight loss

Is Preauth Required? Preauthorization is required for the treatment of semaglutide for weight loss, as this use is off-label and therefore is not approved by the FDA or any of the approved compendia. The route of administration and the drug must also be considered reasonable and necessary for the individual patient. The determination as to whether the medication is reasonable and necessary can be made on appeal. Will the claim be denied? Semaglutide is not a surgical treatment for primary obesity, and therefore is not covered by Medicare. The national coverage policy does not cover this treatment for weight loss. When is the following treatment medically necessary for the condition specified? Semaglutide is approved by the FDA for use in adults with obesity, as an adjunct to diet and exercise, to help reduce body weight. The treatment is considered medically necessary for adults with a BMI of 27 or greater who have been unsuccessful with prior medical treatment for obesity, such as lifestyle modifications and previous unsuccessful medical treatments. What would make the following treatment considered medically necessary? Semaglutide is not mentioned in the given context, so I don't know if it would be considered medically necessary in the context of weight loss. What are the relevant codes for the treatment? The CPT/HCPCS codes for semaglutide treatment for weight loss are 0446T, 0447T, and 0448T. The ICD-10-CM codes that support medical necessity are 275 codes and the primary diagnosis code is from Group 1 Codes and the secondary diagnosis code is from Group 2 Codes. CPT code 64584 will have no diagnosis to procedure code restriction at this time.


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