Prior authorization and covered codes

Clinician-supervised weight reduction counseling codes (97802, 97803, 97804) and medical nutrition HCPCS (G0270, G0271) are covered when selection criteria are met; Plenity is covered when criteria are met though no specific HCPCS code exists.

• Covered CPT: 97802, 97803, 97804 (medical nutrition therapy) when selection criteria are met.
• Covered HCPCS: G0270, G0271 when selection criteria are met.
• Plenity (Gelesis) is considered medically necessary for BMI 25–40 kg/m2 when used with diet and exercise; no specific HCPCS code is listed.

Prior authorization expectations for liraglutide

Initiation and continuation of liraglutide (Saxenda) must be justified by BMI criteria (BMI ≥30 kg/m2 or BMI ≥27 kg/m2 with at least one weight‑related comorbidity) and therapy should be evaluated at 16 weeks to document response.

• Document baseline BMI/weight and comorbidities to support initiation (BMI ≥30 or ≥27 with comorbidity).
• Evaluate weight loss at 16 weeks and discontinue if the patient has not lost ≥4% of baseline body weight per FDA labeling.

Plenity: labeling, indication, and dosing

Plenity is FDA‑cleared as an adjunct to diet and exercise for adults with BMI 25–40 kg/m2; device labeling specifies dosing of three capsules (2.25 g/dose) with water before lunch and dinner and recommends use within a structured weight loss program.

• Each dose: three (3) capsules = 2.25 g, taken with water before lunch and dinner.
• Indication: adults with BMI 25–40 kg/m2, used in conjunction with diet and exercise.
• Payer documentation may require evidence of selection criteria and concurrent lifestyle measures evaluated in trials.

Prior authorization — none specified

The background/appendix supplies BMI and ideal body weight calculators (MDCalc and CDC BMI) to support clinical measurement but does not list specific prior authorization requirements in this section.

• MDCalc link for ideal and adjusted body weight (Devine formula) and CDC adult BMI calculator are provided.
• No explicit prior authorization codes or requirements are specified in the appendix/background chunks.

Prior authorization (not specified here)

This section of the background does not include specific prior authorization code requirements; see main policy sections for any plan-specific prior authorization procedures.

• Clinical Policy Bulletin is a partial description of plan benefits and does not substitute for plan provisions that may include prior authorization rules.

Medication adjunct requirement

Weight reduction medications should be used as adjuncts to diet, exercise, and behavioral modification and reserved for patients who have not achieved adequate weight loss with lifestyle measures alone.

• Consider pharmacotherapy only after documented failure of caloric restriction, increased physical activity, and behavioral modification.
• Initial response (e.g., lack of ≥2 kg weight loss in first 4 weeks) predicts poor long‑term response and should inform continuation decisions.

Concomitant therapy restriction

Do not combine liraglutide (Saxenda) with other GLP‑1 receptor agonists (for example, Victoza); liraglutide is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN2).

• Saxenda and Victoza contain the same active ingredient at different doses; concurrent use is not indicated.
• Boxed warning and contraindications for MTC and MEN2 must be reviewed and documented.

Requirement for concurrent lifestyle program

Plenity effectiveness in trials was measured with concurrent diet and exercise; payers may require documentation that patients are participating in and adhering to a structured lifestyle modification program while using Plenity.

• GLOW trial prescribed reduced caloric intake and exercise for all subjects; documentation of lifestyle counseling/adherence may be requested.
• Plenity is intended for use as an adjunct to diet and exercise, not as a standalone substitute for nutritional intake.

No step therapy requirements described

No step therapy requirements for SGLT2 inhibitors or other agents are described in these background chunks; the document does not define a step‑therapy sequence in this section.

• Background material reports evidence reviews but does not establish payer step therapy rules here.
• Refer to pharmacy PA policy for specific step therapy or formulary requirements.

Required clinical tests and monitoring

For VLCDs and medical evaluation of overweight/obese individuals, document ordered/performed baseline and monitoring tests including CBC, metabolic/chemistry profiles, lipid profile, thyroid tests, glucose tolerance testing (when indicated), ECG (adult), and scheduled serum chemistries and LFTs weekly during rapid weight loss then every 2 weeks up to 16 weeks.

• Baseline evaluation: CBC, comprehensive history and physical, lipid profile, metabolic and chemistry profile, thyroid function tests, urinalysis, ECG (adult), GTT when indicated.
• VLCD monitoring: EKG after 50 lbs lost; lipid profile at start and end; weekly serum chemistries and LFTs during rapid phase, then every 2 weeks up to 16 weeks.

Required documentation for GLP-1 receptor agonist therapy

When prescribing GLP‑1 receptor agonist therapy (liraglutide), document baseline BMI and weight, any weight‑related comorbidities, contraindications (personal/family history of MTC or MEN2), and weight change at approximately 16 weeks to justify continuation or discontinuation.

• Record baseline BMI/weight and presence of weight‑related comorbidities to meet indication criteria (BMI ≥30 or ≥27 with comorbidity).
• Capture and document percent weight change at ~16 weeks to determine whether liraglutide should be discontinued if <4% weight loss.

Patient counseling and documentation

Advise patients taking Plenity to take the product under the direction of a healthcare provider as part of a structured weight loss program and to discontinue and contact their HCP for severe adverse events, inability to swallow capsules, or if capsules are damaged.

• Patients should stop Plenity and contact HCP for severe allergic reaction, severe abdominal pain, or severe diarrhea.
• Do not use Plenity in pregnancy or with known allergies to cellulose, citric acid, sodium stearyl fumarate, gelatin, or titanium oxide.

Weight and BMI calculation resources

Links to external calculators (MDCalc for ideal/adjusted body weight using the Devine formula and CDC adult BMI calculator) are provided to support consistent weight and BMI calculations; providers should use these resources when documenting BMI and weight.

• MDCalc: Ideal Body Weight and Adjusted Body Weight (Devine formula).
• CDC Adult BMI Calculator for computing BMI.

Clinical policy bulletin note

Clinical Policy Bulletins provide a partial, general description of plan benefits and do not constitute a contract; providers remain responsible for treatment decisions and must follow specific plan provisions which may affect coverage or authorization.

• Verify member benefit plan details for exclusions or prior authorization requirements before delivering services.
• CPB information may be updated; providers should confirm current plan provisions.

Benefit exclusion may trigger denial

Claims for weight reduction medications and physician supervision of weight reduction programs will be denied if the member's benefit plan specifically excludes services and supplies related to obesity, diet, or weight control—confirm benefits prior to ordering or billing.

• Check benefit plan descriptions for exclusions; under excluded plans, claims will be denied regardless of medical necessity criteria.
• Diagnostic tests required solely by non‑covered weight loss programs are not covered under most plans.

Liraglutide treatment stopping rule

Per FDA labeling for liraglutide (Saxenda), evaluate patients at 16 weeks and discontinue treatment if they have not lost at least 4% of baseline body weight, as continued treatment is unlikely to be effective.

• Document weight at baseline and at 16 weeks to support continuation or discontinuation decisions.
• Failure to meet the 4% threshold should prompt discontinuation per labeling.

Contraindications and precautions for Plenity

Plenity is contraindicated in pregnancy and in patients with a history of allergic reaction to cellulose, citric acid, sodium stearyl fumarate, gelatin, or titanium oxide; use caution or avoid in patients with active GI conditions or anatomic anomalies that affect swallowing or GI transit.

• Avoid Plenity in patients with esophageal anomalies, suspected strictures, prior GI surgery affecting transit, or inability to swallow capsules.
• Instruct patients to discontinue and contact HCP for severe allergic reactions or severe GI symptoms.

None stated in this section

No additional provider actions are specified in these background and evidence summary chunks regarding authorization or denial triggers; refer to the main policy coverage criteria for concrete prior authorization rules.

• Background sections summarize evidence and do not replace the policy's coverage/authorization criteria.
• See policy coverage sections for any required forms, documentation, or authorization workflows.

No explicit authorization or denial trig

These background chunks do not provide explicit authorization or denial triggers; providers should consult the main policy sections and member benefit documents for prior authorization requirements.

• Policy history and additional information sections reiterate that CPBs are partial descriptions and plan provisions govern coverage.
• Contact the payer for specific prior authorization processes when codes/services are planned.