What ICD-10 (International Classification of Diseases, 10th Revision) code can I use to get Wegovy (semaglutide) approved for a patient with obesity?

ICD-10 Codes for Wegovy (Semaglutide) Approval

For insurance approval of Wegovy, use ICD-10 code E66.01 (Morbid obesity due to excess calories) for patients with BMI ≥30 kg/m², or E66.9 (Obesity, unspecified) combined with a weight-related comorbidity code for patients with BMI ≥27 kg/m² with at least one obesity-associated condition.

Primary Obesity Codes

The most commonly accepted ICD-10 codes for Wegovy approval are:

• E66.01 - Morbid obesity due to excess calories (BMI ≥30 kg/m²) 1, 2
• E66.9 - Obesity, unspecified (BMI ≥30 kg/m²) 1, 2
• E66.8 - Other obesity (BMI ≥30 kg/m²) 1, 2

BMI-Specific Codes to Include

Always pair the obesity code with a specific BMI code for stronger documentation:

• Z68.41 - BMI 40.0-44.9, adult 1
• Z68.42 - BMI 45.0-49.9, adult 1
• Z68.43 - BMI 50.0-59.9, adult 1
• Z68.44 - BMI 60.0-69.9, adult 1
• Z68.45 - BMI 70 or greater, adult 1
• Z68.35-Z68.39 - BMI 27.0-29.9 range for overweight with comorbidities 1

Weight-Related Comorbidity Codes (Required for BMI 27-29.9)

For patients with BMI ≥27 kg/m² but <30 kg/m², you must include at least one of these comorbidity codes:

• E11.9 - Type 2 diabetes mellitus without complications 1, 2
• I10 - Essential (primary) hypertension 1, 2
• E78.5 - Hyperlipidemia, unspecified 1, 2
• E78.0 - Pure hypercholesterolemia 1
• E78.1 - Pure hypertriglyceridemia 1
• G47.33 - Obstructive sleep apnea 1
• I25.10 - Atherosclerotic heart disease without angina pectoris 1, 2
• K76.0 - Fatty liver disease (NAFLD/MASLD) 1

FDA-Approved Indications Requiring Specific Codes

Wegovy is FDA-approved for two distinct indications, each requiring specific coding:

Indication 1: Chronic Weight Management

• Primary requirement: BMI ≥30 kg/m² OR BMI ≥27 kg/m² with ≥1 weight-related comorbidity 2, 3, 4
• Must document: Adjunct to reduced-calorie diet and increased physical activity 2, 1

Indication 2: Cardiovascular Risk Reduction

• E66.9 (Obesity) PLUS I25.10 (Established cardiovascular disease) 2
• Specific criteria: Adults with BMI ≥27 kg/m² AND established cardiovascular disease (prior MI, stroke, peripheral arterial disease, or revascularization) 2
• This indication does NOT require diabetes 2

Critical Documentation Requirements

To maximize approval likelihood, your documentation must include:

• Current BMI calculation with height and weight documented within the past 30 days 1
• Documentation of failed lifestyle modification attempts (diet and exercise for ≥3-6 months) 1, 5
• Absence of contraindications: No personal or family history of medullary thyroid cancer (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN2) 2, 1
• Clear statement: "Patient meets FDA criteria for Wegovy: BMI [value] kg/m² with [comorbidity if applicable]" 2, 1

Common Pitfalls to Avoid

Do not use these codes alone, as they will likely result in denial:

• E66.3 (Overweight) - This code indicates BMI 25-29.9 without comorbidities and does not meet FDA criteria 1
• Z71.3 (Dietary counseling) - This is a supplementary code, not a primary diagnosis 1
• Obesity codes without BMI Z-codes - Always pair them together for complete documentation 1

Never code for "weight loss" as the primary indication - Wegovy is approved for "chronic weight management" in obesity, not simple weight loss 2, 3

Optimal Coding Strategy

For maximum approval success, use this combination:

1. Primary diagnosis: E66.01 or E66.9 (obesity code) 1, 2
2. Secondary diagnosis: Z68.4X (specific BMI code) 1
3. Additional diagnoses: Any applicable comorbidity codes (I10, E11.9, E78.5, etc.) 1, 2
4. Supporting code: Z68.1 (Body mass index [BMI] pediatric) if applicable, or Z71.3 (Dietary counseling and surveillance) as supplementary 1

Example for BMI 38 with hypertension and prediabetes:

• E66.01 (Morbid obesity due to excess calories)
• Z68.38 (BMI 38.0-38.9, adult)
• I10 (Essential hypertension)
• R73.03 (Prediabetes)

Example for BMI 28 with type 2 diabetes and dyslipidemia:

• E66.9 (Obesity, unspecified)
• Z68.27 (BMI 27.0-27.9, adult)
• E11.9 (Type 2 diabetes mellitus without complications)
• E78.5 (Hyperlipidemia, unspecified)

Insurance-Specific Considerations

Most commercial insurers require:

• Pre-authorization with documented BMI ≥30 kg/m² or ≥27 kg/m² with comorbidities 1, 5
• Documentation of 3-6 months of supervised lifestyle modification attempts 1, 5
• Absence of contraindications explicitly stated 2, 1

Medicare typically does NOT cover Wegovy for obesity alone (as of 2024), but may cover if the patient has established cardiovascular disease under the cardiovascular risk reduction indication 2

The average wholesale price is approximately $1,557-$1,619 per 30-day supply, making prior authorization documentation critical 5