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This synthetic peptide is 94% identical to the naturally occurring human GLP-1 hormone but includes two amino acid modifications that allow it to resist enzyme breakdown in the body
Lancet 352:854865 Dujic T, Zhou K, Donnelly LA, Tavendale R, Palmer CN, Pearson ER (2015) Association of organic cation transporter 1 with intolerance to metformin in type 2 diabetes: a GoDARTS study
As this is below the threshold of 100 claims for a service within a year, we propose to apply our universal low volume APC policy and use the highest of the geometric mean cost, arithmetic mean cost, or median cost based on up to 4 years of claims data to assign CPT code 0686T to the appropriate New Technology APC
Key takeaway Anthem may cover Wegovy for weight loss, but eligibility criteria and prior authorization requirements apply
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