A denial is a first decision, not a final one. You have a legal right to an internal appeal, and if that fails, to an independent external review by a reviewer your insurer does not employ. Appeals succeed most often when they answer the specific reason given in the denial letter and attach the documentation that was missing the first time.
This is one part of getting a GLP-1 covered. For the full picture, see GLP-1 Insurance Coverage: The Complete Guide.
First: read the denial letter properly
The letter must state the reason. That reason determines your entire strategy, and it will usually be one of four things.
Not medically necessary. The reviewer decided the criteria were not met. Your appeal supplies the clinical evidence that they are.
Benefit exclusion. Your plan does not cover anti-obesity medications at all. This is the hardest to overturn, because it is not a clinical judgment — it is a contract term. Your route is usually through your employer rather than through appeal.
Step therapy not completed. You need to try something else first. File a step therapy exception rather than a standard appeal.
Insufficient documentation. The most common and the most winnable. Supply what was missing.
The letter also states your deadline. Note it. Missing an appeal deadline forfeits the right, and the windows are often 180 days but can be shorter.
The appeal letter
Keep it to one page plus attachments. Reviewers are working through volume; a focused letter beats an emotional one.
[Your name] [Member ID] · [Group number] [the date on your letter] RE: Appeal of denial — Wegovy (semaglutide) Claim/reference number: [from denial letter] Date of denial: [the date on your letter] To the Appeals Department, I am appealing the denial dated [the date on your letter] for Wegovy (semaglutide), prescribed by [prescriber name, NPI]. The denial states the reason as: "[quote the exact wording from the letter]." I am providing the following in response: 1. Clinical criteria. My measured BMI is [X], recorded at a visit on [the date on your letter] (attached). I have a documented diagnosis of [comorbidity], coded [ICD-10 code], supported by [lab value or study, attached]. 2. Prior weight management. I completed [program name] from [the date on your letter] to [the date on your letter], a period of [X] months, under [supervision type]. My weight went from [X] to [Y] and returned to [Z] by [the date on your letter]. Records attached. 3. Medical necessity. My prescriber's letter of medical necessity is attached, addressing why this treatment is appropriate for my clinical situation. This request meets the criteria set out in [insurer]'s clinical policy [policy number, if you have it]. I request a full and fair review, and I am requesting a copy of all documents and criteria used in the original determination. Sincerely, [Signature] [Phone] · [Email] Attachments: - Copy of denial letter - Prescriber letter of medical necessity - Clinical visit notes with measured BMI - Documentation of prior weight management attempts - Relevant lab results
What makes an appeal work
Quote the denial reason verbatim and answer it directly. Reviewers are checking whether the objection has been addressed, not reading a narrative.
Attach a real letter of medical necessity from your prescriber. Ask them for one explicitly — many will write it if asked, and few will volunteer it.
Request the criteria used. You are entitled to it, and asking signals you know the process.
Send it in a way you can prove: certified mail, or the plan portal with a screenshot of the submission confirmation.
Keep a log of every call, with date, name, and reference number.
If the internal appeal fails
You can generally request an external review — an independent organization not employed by your insurer reviews the case, and their decision is binding on the plan. This is a meaningful right and it is underused.
If you believe the plan has handled the process improperly, you can also file a complaint with your state insurance commissioner, which is free and sometimes prompts movement on its own.
Before writing anything, check which category your refusal falls into. A documentation gap is fixable; a benefit exclusion is not appealable on clinical grounds. If the internal appeal fails, external review puts it to an independent reviewer whose decision binds the plan.
Frequently asked questions
How long do I have to appeal?
Your denial letter states the deadline. Many plans allow 180 days, but some are shorter. Do not rely on the general figure — read the letter.
How long does the insurer have to respond?
Timeframes vary by plan type and whether the request is standard or urgent. The letter should state them; if it does not, call and ask for the timeframe in writing.
Can my doctor appeal for me?
Yes, and a peer-to-peer review — where your prescriber speaks directly to the plan’s medical director — is often more effective than a written appeal. Ask your prescriber to request one.
Does appealing ever make things worse?
No. There is no penalty for appealing, and a denial cannot be made more restrictive because you challenged it.
What if the denial says anti-obesity drugs are excluded?
Appeals rarely overturn a contract exclusion, because it is not a clinical decision. Your leverage is at the employer level, at the next plan year.
Should I just pay cash while I appeal?
That is a personal financial decision. Be aware that self-pay months generally do not count toward any plan requirement.
Sources
- Department of Labor, ERISA claims and appeals, 29 CFR 2560.503-1 — dol.gov
- HealthCare.gov, internal appeals and external review — healthcare.gov
- Centers for Medicare & Medicaid Services, appeals process — cms.gov