Your GLP-1 was denied — here's how to fight it

A denial is not the end. Insurers deny on specific, listed criteria, and a documented, well-framed appeal overturns a meaningful share of them. Here's the playbook.

1. Get the denial in writing. Ask your plan for the written denial and the specific reason/criteria cited. You can't fight what you can't see. Note the appeal deadline (often 60–180 days).
2. Find the exact coverage criteria. Request your plan's medical/pharmacy policy for the drug. Denials usually hinge on specific, listed criteria (BMI threshold, documented comorbidity, prior diet attempts, step therapy). You're checking which box they say you missed.
3. Match your record to every criterion. Have your clinician document each met criterion in the chart — BMI history, comorbidities (e.g., hypertension, sleep apnea, prediabetes, cardiovascular risk), and prior weight-loss attempts. Specifics win appeals.
4. Use the strongest indication. If a drug has a covered indication you qualify for (e.g., Wegovy's cardiovascular-risk-reduction indication, or a diabetes diagnosis for semaglutide/tirzepatide), make sure the request is framed to it — that's often the difference.
5. File the appeal with a letter of medical necessity. Your clinician submits a letter of medical necessity tying your documented record to each policy criterion. Use our template as a starting point — then have your clinician personalize and sign it.
6. Escalate: peer-to-peer, then external review. If denied again, request a peer-to-peer review (your doctor vs. theirs) and then an independent external review — a neutral third party overturns a meaningful share of denials.

Letter of medical necessity — starter template

Give this to your prescriber as a starting point. They must personalize it to your record and sign it — an appeal succeeds on YOUR documented specifics, not a generic letter.

[Date]
[Insurer / Pharmacy Benefit Manager]
Re: Appeal of coverage denial — [Patient name], Member ID [#], [Drug name] for [indication]

To the Medical Review Department:

I am the treating clinician for [Patient]. I am appealing the denial dated [date] for [drug]. Based on your plan's published coverage criteria for this medication, [Patient] meets the following requirements:

  • Diagnosis / indication: [e.g., obesity with BMI of __; or BMI __ with comorbidity __; or established cardiovascular disease for which this agent is FDA-indicated].
  • Documented comorbidities: [hypertension / obstructive sleep apnea / prediabetes / dyslipidemia / cardiovascular disease — list with dates].
  • Prior weight-management attempts: [diet/lifestyle program(s), other agents tried/failed — with dates].
  • Any required step therapy: [completed / medically inappropriate because __].

Each criterion above is supported in the enclosed records. Denying coverage is not consistent with your own published medical policy, and the requested therapy is medically necessary for this patient.

I request approval, or alternatively a peer-to-peer review and, if needed, independent external review.

Sincerely,
[Clinician name, credentials, NPI, contact]