How to Appeal a GLP-1 Insurance Denial (And Win)

The Number Most People Don't Know

Here's the statistic that should change how you think about GLP-1 denials: appeals succeed more than 65% of the time. Yet 85% of patients who are denied coverage never file an appeal.

That means millions of Americans are paying out-of-pocket (or going without treatment) for medications their insurance might actually cover—they just gave up too soon.

This guide walks you through exactly how to appeal a denial and maximize your chances of success.

Understanding Why You Were Denied

Before you can fight a denial, you need to understand it. Here are the most common denial reasons and what they actually mean:

🚫 "Not Medically Necessary"

Your documentation didn't convince them you need this medication. Usually means they don't see sufficient BMI documentation or comorbidities.

Solution: Submit detailed records showing BMI ≥30 (or ≥27 with comorbidities), lab work, and documented health conditions like hypertension, sleep apnea, or prediabetes.

🚫 "Step Therapy Required"

They want you to try cheaper medications first (like phentermine, orlistat, or Contrave) before approving GLP-1s.

Solution: Document previous weight loss attempts (diets, exercise programs, other medications) and explain why they failed or why step therapy is medically inappropriate for you.

🚫 "Prior Authorization Not Obtained"

The prescription was filled before your insurer approved it. This is a procedural issue, not a coverage issue.

Solution: Request retroactive prior authorization or have your doctor submit a new PA with complete documentation before your next fill.

🚫 "Excluded from Formulary" / "Not Covered"

Your specific plan doesn't include this medication on their approved drug list.

Solution: Request a formulary exception based on medical necessity. Argue that no formulary alternative provides equivalent therapeutic benefit.

🚫 "Cosmetic / Lifestyle" Classification

Insurer is claiming weight loss is elective, not medical treatment.

Solution: Emphasize obesity as a chronic disease (ICD-10: E66) with documented health consequences. Include any comorbidities that establish medical necessity.

The 5-Step Appeal Process

Get Your Denial in Writing

Call your insurer and request the written denial letter with specific reason codes. You have a legal right to this document. Note the deadline for appeals (typically 180 days for internal appeals).
Gather Your Documentation

Collect everything that supports medical necessity: BMI measurements over time, list of comorbidities with diagnosis codes, records of previous weight loss attempts, lab work (A1C, lipids, liver enzymes), and any specialist notes.
Get a Letter of Medical Necessity

Ask your prescribing doctor to write a detailed letter explaining why this specific medication is necessary for your health. The more specific, the better—reference clinical guidelines and your individual health history.
File Your Internal Appeal (Level 1)

Submit your appeal in writing with all supporting documentation. Address each denial reason specifically. Reference your plan's own coverage criteria and explain how you meet them.
Request External Review (Level 2)

If your internal appeal is denied, you can request an external review by an Independent Review Organization (IRO). This is decided by a third party, not your insurer—and they often rule in patients' favor.

Documentation Checklist

📋 What to Include in Your Appeal

Denial letter with reason codes
BMI documentation from multiple visits (ideally showing BMI ≥30 or ≥27)
Comorbidity documentation: hypertension, type 2 diabetes, sleep apnea, PCOS, fatty liver, etc.
Previous weight loss attempts: diet programs, exercise regimens, other medications tried
Lab work: A1C, fasting glucose, lipid panel, liver enzymes
Letter of Medical Necessity from your doctor
Clinical guidelines supporting GLP-1 use for your condition
Your written appeal letter addressing each denial reason

Sample Appeal Letter Template

[DATE]

[INSURANCE COMPANY NAME]
Appeals Department
[ADDRESS]

RE: Appeal of Claim Denial
Member Name: [YOUR NAME]
Member ID: [YOUR ID NUMBER]
Claim Number: [CLAIM NUMBER]
Medication: [WEGOVY/ZEPBOUND/etc.]

Dear Appeals Committee,

I am writing to formally appeal the denial of coverage for [MEDICATION NAME], which was denied on [DENIAL DATE] with reason code [REASON CODE].

I respectfully request that you reconsider this decision based on the following medical evidence demonstrating that this medication is medically necessary for my treatment:

Diagnosis and Medical Necessity:
I have been diagnosed with obesity (ICD-10: E66.9) with a documented BMI of [YOUR BMI]. Additionally, I have the following obesity-related comorbidities: [LIST CONDITIONS].

Previous Treatment Attempts:
Prior to this prescription, I attempted the following weight management interventions without sustained success: [LIST PREVIOUS ATTEMPTS - diets, exercise programs, other medications].

Clinical Support:
According to the American Association of Clinical Endocrinology (AACE) and the American Academy of Obesity Medicine guidelines, GLP-1 receptor agonists are recommended as first-line pharmacotherapy for patients with BMI ≥30 or BMI ≥27 with comorbidities.

Enclosed please find supporting documentation including my physician's Letter of Medical Necessity, BMI records, lab work, and documentation of comorbidities.

I respectfully request that you approve coverage for [MEDICATION NAME] as medically necessary treatment for my chronic disease. Please contact me at [YOUR PHONE] or [YOUR EMAIL] if you require additional information.

Sincerely,
[YOUR SIGNATURE]
[YOUR PRINTED NAME]

💡 Pro Tip: Reference your plan's own coverage criteria in your appeal. If they require BMI ≥30, explicitly state "Patient meets coverage criteria with documented BMI of 32.4 as of [date]." Make it easy for the reviewer to check boxes.

When to Get Professional Help

If your appeals are complex or you've already been denied multiple times, consider professional appeal services:

Counterforce Health and Honest Care specialize in GLP-1 insurance appeals. They understand the system, know which arguments work, and have documented success rates exceeding 65%.

These services typically charge a fee only if they win your appeal, making them a low-risk option if you're struggling with the process.

Timeline Expectations

Internal Appeal: Insurers must respond within 30-60 days for non-urgent requests (72 hours for urgent/expedited appeals).

External Review: Independent Review Organizations typically decide within 45 days.

Total Process: If you go through both levels, expect 2-4 months from initial appeal to final decision.

✓ Don't Give Up Too Soon: Many successful appeals happen at the external review level, even after internal appeals are denied. The external reviewer is independent and often more sympathetic to patient needs.

What If You Lose?

If your appeal is ultimately denied, you still have options:

Manufacturer self-pay programs: Wegovy at $349/mo via NovoCare, Zepbound at $299-449/mo via LillyDirect
Compounded alternatives: $149-299/mo for semaglutide from telehealth providers
Patient assistance programs: Free medication for qualifying low-income patients
Different indication: If you have diabetes, the medication may be covered under that diagnosis

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