Prescription drugs: 75% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Overturned 2026 · Medical necessity · age 11–20 Hormones · Hormones and metabolism The physician reviewer found that a patient has requested authorization and coverage for Omnitrope. The patient has a history of growth hormone deficiency and idiopathic short stature, with persistently low growth velocity and failure to pass a growth…

   The physician reviewer found that a patient has requested authorization and coverage for Omnitrope. The patient has a history of growth hormone deficiency and idiopathic short stature, with persistently low growth velocity and failure to pass a growth stimulation test, confirming the diagnosis of GHD. The record shows that the patient has been receiving Omnitrope, and continued therapy is appropriate to support growth in this clinical setting. Therefore, the requested Omnitrope is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the medication is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in pediatrics with a subspecialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46986

2. Overturned 2026 · Medical necessity · age 51–64 Biologics · Skin The physician reviewer found that a patient has requested authorization and coverage for Taltz. The patient has psoriatic arthritis and has shown sustained clinical improvement on Taltz after failing prior biologic therapies, including Enbrel and Cosentyx…

   The physician reviewer found that a patient has requested authorization and coverage for Taltz. The patient has psoriatic arthritis and has shown sustained clinical improvement on Taltz after failing prior biologic therapies, including Enbrel and Cosentyx. The medical records document meaningful improvement in symptoms and function with this treatment. Given the patient’s history of inadequate response to other therapies and the stability achieved on Taltz, continuation of this medication is clinically appropriate. Therefore, the requested Taltz is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46985

3. Upheld 2026 · Medical necessity · age 41–50 Antivirals · Infection The physician reviewer found that a patient has requested authorization and coverage for Vemlidy. The patient has chronic hepatitis B and was initially treated with tenofovir, which remains a first‑line therapy. The medical record does not document clinical…

   The physician reviewer found that a patient has requested authorization and coverage for Vemlidy. The patient has chronic hepatitis B and was initially treated with tenofovir, which remains a first‑line therapy. The medical record does not document clinical factors that would justify switching from tenofovir fumarate to Vemlidy. Therefore, the requested Vemlidy is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certifications in gastroenterology and transplant hepatology, and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46980

4. Overturned 2026 · Medical necessity · age 41–50 Weight-loss drugs · Hormones and metabolism The physician reviewer found that a patient has requested authorization and coverage for Wegovy. The patient’s BMI exceeds 40 kg/m², and Wegovy is an FDA‑approved medication for chronic weight management in individuals with obesity. The medical records…

   The physician reviewer found that a patient has requested authorization and coverage for Wegovy. The patient’s BMI exceeds 40 kg/m², and Wegovy is an FDA‑approved medication for chronic weight management in individuals with obesity. The medical records indicate that the patient has made prior attempts at weight loss without adequate success. In this clinical context, medical literature supports the use of Wegovy as an appropriate treatment option. Therefore, the requested Wegovy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46978

5. Overturned 2026 · Medical necessity · age 41–50 Weight-loss drugs · Hormones and metabolism The physician reviewer found that a patient has requested authorization and coverage for Zepbound. Zepbound is FDA‑approved for chronic weight management in adults with obesity or overweight with a weight‑related comorbidity. The patient has class 3 obesity…

   The physician reviewer found that a patient has requested authorization and coverage for Zepbound. Zepbound is FDA‑approved for chronic weight management in adults with obesity or overweight with a weight‑related comorbidity. The patient has class 3 obesity and hypertension and has participated in structured lifestyle modification, including a medically supervised weight‑loss program and behavioral therapy. Despite these efforts, adequate weight loss has not been achieved. Given the patient’s clinical history and the support in medical literature for Zepbound in this setting, the requested medication is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46977

6. Overturned 2026 · Medical necessity · age 41–50 Other drugs · Digestive system The physician reviewer found that a patient has requested authorization and coverage for ondansetron tablets 4 mg, 180 tablets per 30 days. Ondansetron is an accepted therapy for chronic nausea associated with gastroparesis, and medical literature supports…

   The physician reviewer found that a patient has requested authorization and coverage for ondansetron tablets 4 mg, 180 tablets per 30 days. Ondansetron is an accepted therapy for chronic nausea associated with gastroparesis, and medical literature supports its use when symptoms persist despite other antiemetics. The records show that this patient has gastroparesis, has failed multiple alternative treatments, and has been successfully managed with ondansetron over time. Given the patient’s ongoing symptoms and prior treatment history, the requested dosing is clinically appropriate. For these reasons, ondansetron 4 mg three times daily (up to 180 tablets per 30 days) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46972

7. Overturned 2026 · Medical necessity · age 51–64 Anti-inflammatories · Digestive system The physician reviewer found that a patient has requested authorization and coverage for Rinvoq. The patient has a history of Crohn’s disease and has previously been treated with two advanced therapies without adequate improvement. Although recent evaluation…

   The physician reviewer found that a patient has requested authorization and coverage for Rinvoq. The patient has a history of Crohn’s disease and has previously been treated with two advanced therapies without adequate improvement. Although recent evaluation did not show active inflammation, the patient continues to experience significant symptoms that impair daily functioning. Rinvoq is FDA‑approved for Crohn’s disease, and medical literature supports its use in patients who have not responded to other treatments. Given the patient’s ongoing symptoms despite prior therapy, Rinvoq is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46971

8. Upheld 2026 · Medical necessity · age 41–50 GLP-1 drugs · Hormones and metabolism The physician reviewer found that a patient has requested authorization and coverage for Ozempic. Ozempic (semaglutide) is FDA‑approved for the management of blood glucose in patients with type 2 diabetes, and supporting clinical studies evaluated adults with…

   The physician reviewer found that a patient has requested authorization and coverage for Ozempic. Ozempic (semaglutide) is FDA‑approved for the management of blood glucose in patients with type 2 diabetes, and supporting clinical studies evaluated adults with this diagnosis. In this case, the patient received Ozempic based on a diagnosis of type 2 diabetes; however, the medical records do not support this diagnosis prior to treatment. The patient’s hemoglobin A1c values are consistent with prediabetes, for which first‑line therapy includes lifestyle modification or metformin. Ozempic is not FDA‑approved for prediabetes. Although semaglutide has other approved indications, Ozempic is not FDA‑approved for the treatment of prediabetes or MASH. For these reasons, the requested Ozempic is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46957

9. Upheld 2026 · Medical necessity · age 21–30 Weight-loss drugs · Hormones and metabolism The physician reviewer found that a patient has requested authorization and coverage for Zepbound. The patient has a history of obesity, and the medical record includes recommendations for lifestyle modification. However, the documentation does not show that…

   The physician reviewer found that a patient has requested authorization and coverage for Zepbound. The patient has a history of obesity, and the medical record includes recommendations for lifestyle modification. However, the documentation does not show that the patient has trialed dietary changes or exercise as part of a structured weight‑loss effort. As such, the requested medication, Zepbound, is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the medication is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the member's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46949

10. Upheld 2026 · Medical necessity · age 11–20 Injection admin drugs · Sym/Sign Ab Find The physician reviewer found that the parent of a patient has requested authorization and coverage for Omnitrope. The essential diagnostic criteria for idiopathic short stature (ISS), according to the U.S. Food and Drug Administration (FDA) and the Pediatric…

    The physician reviewer found that the parent of a patient has requested authorization and coverage for Omnitrope. The essential diagnostic criteria for idiopathic short stature (ISS), according to the U.S. Food and Drug Administration (FDA) and the Pediatric Endocrine Society, include a standing height significantly below the mean and the absence of identifiable pathology prior to growth hormone therapy. Based on the records, the patient’s height does not meet the degree of short stature required for ISS. This patient’s clinical presentation was also inconsistent with pediatric growth hormone deficiency. Overall, the facts of this case do not support a diagnosis of pediatric growth hormone deficiency. All told, the requested Omnitrope is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in pediatrics with subspecialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN26-46948

11. Upheld 2026 · Medical necessity · age 31–40 Anxiety drugs · Mental health The physician reviewer found that a patient has requested authorization and coverage for an increased dosage of Xanax. The patient's provider has evaluated the patient and determined that the patient is not a good candidate for an increased dosage or…

    The physician reviewer found that a patient has requested authorization and coverage for an increased dosage of Xanax. The patient's provider has evaluated the patient and determined that the patient is not a good candidate for an increased dosage or increased quantity of tablets. Benzodiazepines, including alprazolam, carry significant risks of abuse, misuse, physical dependence, and withdrawal that increase with higher doses and longer treatment duration. These risks are particularly relevant for this patient, who is taking medication for co‑occurring conditions. All told, the requested increased dosage of Xanax is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN26-46938

12. Upheld 2026 · Medical necessity · age 11–20 Other drugs · Brain and nerves The physician reviewer found that a patient has requested authorization and coverage for Wakix. The American Academy of Sleep Medicine (AASM) clinical practice guidelines note that treatment of idiopathic hypersomnia begins with confirmation of the diagnosis…

    The physician reviewer found that a patient has requested authorization and coverage for Wakix. The American Academy of Sleep Medicine (AASM) clinical practice guidelines note that treatment of idiopathic hypersomnia begins with confirmation of the diagnosis and exclusion of other causes of excessive daytime sleepiness. Once confirmed, pharmacologic therapy is recommended, with modafinil strongly supported as a first‑line option. Wakix is approved by the U.S. Food and Drug Administration (FDA) for the treatment of excessive daytime sleepiness or cataplexy in narcolepsy but is not FDA‑approved for idiopathic hypersomnia. Per the medical records, the patient has a diagnosis of idiopathic hypersomnia and is taking modafinil at a dosage that has not been optimized. In this clinical setting, given that FDA indications and current medical literature do not support the use of Wakix for idiopathic hypersomnia, the requested medication is not medically indicated. Therefore, Wakix is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in otolaryngology – head and neck surgery with subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN26-46933