CurrentHealth NetPolicy CP CPA.328

Clinical Policy: Diethylpropion

Policy defines medical necessity criteria, initial and continued therapy requirements, dosing limits, contraindications, and administrative references for coverage of diethylpropion for weight management for Centene-affiliated health plans (commercial line of business).

Policy Summary

PayerHealth Net

PolicyClinical Policy: Diethylpropion

Policy CodePolicy CP CPA.328

Change TypeAnnual reviews (revisions and updates)

Effective DateJun 1, 2018

Next Review Date

Key ActionProvider must submit office chart notes, lab results, or other clinical information supporting that member meets all approval criteria, including participation in a weight loss program with diet, activity, and behavioral modification.

POLICY UPDATE CHANGES

2Q 2024 annual review revised age requirement to ≥ 16 years for documentation of weight loss program and required members to be actively enrolled for at least 6 months in initial criteria.

2Q 2023 annual review changed age requirement to ≥ 17 years (was > 16) and added BMI percentile definition for age 17; removed continued therapy criterion of BMI > 25 kg/m2.

2Q 2025 annual review: no significant changes; references reviewed and updated.

2Formulations (IR, ER)

75 mg/dayMax daily dose

12 weeksMax treatment duration

>=30 kg/m2Adult obesity BMI threshold

Coverage Summary

policy_number: CP CPA.328; policy title: Clinical Policy: Diethylpropion.

Diethylpropion is covered with criteria as a short-term adjunct for management of exogenous obesity and is aligned with participation in a structured weight loss program. Coverage requires documentation of program participation, limits on duration (maximum 12 weeks) and dose (maximum 75 mg per day), and follows Centene-affiliated commercial plan scope.

Key thresholds

BMI adult obesity threshold>= 30 kg/m2

BMI overweight-plus-risk threshold> 27 kg/m2 with at least one obesity-related comorbidity

Adolescent BMI threshold>= 95th percentile BMI-for-age and sex

Maximum treatment duration<= 12 weeks

Maximum daily dose<= 75 mg/day

Initial Therapy Criteria

Covered when ALL of the following are met:

{

"operator":"all",

"children":[

{

"operator":"any",

"label":"Age/BMI requirement (ANY)",

Continuation Therapy Criteria

Documentation Required

Weight loss response required for continuation

For continued therapy, documentation must be submitted showing the member is responding positively to therapy as evidenced by weight loss from baseline.

Other Indications / Exclusions

Diagnoses/Indications Not Authorized

Non-authorized indications: Non-FDA approved indications are not authorized unless supported by off-label use policy CP.CPA.09 or other evidence documenting efficacy and safety

Applicable Codes & Policy References

Policy Reference Numbersmixed

CP CPA.328	Clinical policy reference number for diethylpropion
CP.CPA.190	No coverage / Non-formulary policy referenced
CP.CPA.09	Off-label use policy referenced

Provider Actions & Documentation Requirements

Documentation Required

Submit supporting documentation

Provider must submit office chart notes, lab results, or other clinical information supporting that the member has met all approval criteria, including participation in a weight loss program that involves reduced calorie diet, increased physical activity, and behavioral modification.

Office chart notes documenting program enrollment and adherence
Laboratory results (as applicable)
Documentation from weight loss program or behavioral counselor

Prior Authorization

Prior authorization requirement

Coverage requires meeting the initial criteria and submission of supporting documentation; the policy functions as the medical necessity criteria used for authorization decisions.

Clinical Evidence & Indication

FDA approved indication: Diethylpropion is indicated as a short-term adjunct in weight reduction regimens based on caloric restriction for patients with an initial BMI of 30 kg/m2 or higher, or ≥ 27 kg/m2 with a qualifying comorbidity.

This policy requires alignment with behavioral modification as part of the structured weight loss program, consistent with the ACC/AHA guideline-related change reflected in the policy revisions.

Background & Definitions

Diethylpropion is a sympathomimetic amine (pharmacologic activity similar to amphetamines) indicated as a short-term adjunct to caloric restriction for management of exogenous obesity in patients meeting BMI criteria.

Coverage is aligned with participation in a structured weight loss program (diet, activity, behavioral modification) and is applied within Centene-affiliated commercial health plans per this clinical policy.

Definitions: IR = Immediate release; ER = Extended release; BMI = Body mass index.

Revision History

05.25revisedLatest

2Q 2025 annual review: no significant changes; references reviewed and updated.

05.24revised

2Q 2024 annual review revised age requirement to ≥ 16 years for documentation of weight loss program, added requirement that members have been actively enrolled for at least 6 months in initial criteria, and added behavioral modification requirement per ACC/AHA guidelines.

05.23revised

2Q 2023 annual review changed age requirement to ≥ 17 years (was > 16) and for age 17 added obesity defined as BMI ≥ 95th percentile standardized for age; removed continued therapy criterion of BMI > 25 kg/m2.

Policy Summary

PayerHealth Net

PolicyClinical Policy: Diethylpropion

Policy CodePolicy CP CPA.328

Change TypeAnnual reviews (revisions and updates)

Effective DateJun 1, 2018

Next Review Date

On This Page

{"text":"Age ≥ 18 years and BMI ≥ 30 kg/m2"},

{"text":"Age ≥ 18 years and BMI ≥ 27 kg/m2 with at least one obesity-related comorbidity (e.g., coronary artery/heart disease, hypertension, dyslipidemia, diabetes, obstructive sleep apnea, or other obesity-related medical condition)"},

For adolescents age ≥ 16 to 17 years: BMI ≥ 95th percentile standardized for age and sex (see Appendix D)

"text":"Member has been actively enrolled in a comprehensive weight loss program for at least 6 months and documentation supports participation in a program that includes a reduced-calorie diet, increased physical activity, and behavioral modification",

"note":"Must continue enrollment in the weight loss program as an adjunct to pharmacotherapy."

"label":"Dose limits (ALL)",

{"text":"Maximum total daily dose does not exceed 75 mg/day","note":"Overall maximum for treatment."},

{"text":"Immediate-release (IR) formulation: limit to 3 tablets per day (25 mg PO TID)","note":"IR regimen equals 75 mg/day (3 tablets/day)."},

Extended-release (ER) formulation: limit to 1 tablet per day (75 mg PO QD)

ER regimen equals 75 mg/day (1 tablet/day).

"text":"Provider must submit documentation (e.g., office chart notes, lab results, or other clinical information) supporting that the member has met all approval criteria.",

"note":"Documentation should be included with the authorization request."

Prior Authorization

Prior authorization required

This policy functions as the medical necessity criteria used to make authorization decisions.

Prior authorization is required. Requests must demonstrate that the member meets the Initial Therapy Criteria above and include supporting documentation (office notes, weight-loss program documentation, BMI, comorbidity documentation, and prior treatment attempts).

Billing Rule

Dose and duration limits

Dose and duration limits apply.

Maximum total daily dose: 75 mg/day.
Maximum treatment duration: 12 weeks (short-term adjunct to weight-loss program).
IR formulation dosing: 25 mg PO TID (3 tablets/day = 75 mg/day).
ER formulation dosing: 75 mg PO QD (1 tablet/day = 75 mg/day).

Operational notes: For initial approval members must have been actively enrolled in a weight loss program for at least 6 months and providers must submit supporting documentation (e.g., office chart notes, lab results).

Required program elements: the weight loss program must include a reduced calorie diet, increased physical activity, and behavioral modification.

Age thresholds: adults are ≥ 18 years for BMI-based adult criteria; adolescent obesity guidance uses the ≥ 95th percentile BMI-for-age and sex threshold (see Appendix D).