Appeal letter template — denied PA for GLP-1 medications

This is gold. The key elements people miss on appeals:

Documentation of ALL lifestyle modifications attempted

This is what trips most people up. Insurers want to see documented, supervised weight management attempts. "I tried dieting and exercise" isn't enough. They want:

• Records from a registered dietitian or nutritionist
• Documented participation in a structured program (medical weight management, etc.)
• At least 3-6 months of documented attempt
• Objective evidence it didn't work (weight measurements over time)

If you haven't done a supervised program yet, talk to your PCP about starting one NOW so you have the documentation for your appeal. Some insurers will accept a concurrent approach (starting the program while the PA is being processed).

Endocrinologist here. I write 15-20 letters of medical necessity per month for GLP-1 PAs. Here are the elements that make the biggest difference:

1. Use the insurer's own criteria against them. Get their clinical policy bulletin and address each criterion point by point. If they require BMI > 30 with comorbidity, state the BMI and list every qualifying comorbidity with ICD-10 codes.
2. Cite clinical guidelines. The Endocrine Society, AMA, and AAP all recommend GLP-1 RAs for obesity management. Quote specific guideline recommendations.
3. Include the SELECT trial data if the patient has cardiovascular risk. The 20% MACE reduction is hard for insurers to argue against.
4. Frame it as medical necessity, not elective. Obesity is a chronic disease (ICD-10: E66.01). The language matters — "medically necessary treatment for a chronic disease" vs. "weight loss medication."

InsuranceTom, your letter hit all the right notes. Happy to review appeal letters for community members — just DM me (no charge, this is a passion area for me).

Thank you for this. I'm in the middle of my first appeal with UHC right now. They denied my Zepbound PA saying "tirzepatide is not on the preferred formulary for weight management."

Their formulary shows Wegovy as preferred and Zepbound as non-preferred. But my doctor specifically wants me on tirzepatide because of my insulin resistance (fasting insulin 24, HOMA-IR 5.8). She says the dual GIP/GLP-1 mechanism is more appropriate for my metabolic profile.

Is "medical justification for non-preferred agent" a viable appeal route? Or should I just switch the request to Wegovy to get approved faster?

Both are viable but different timelines. If your doctor has strong clinical rationale for tirzepatide over semaglutide — and insulin resistance with HOMA-IR of 5.8 IS a strong rationale — then appealing for the non-preferred agent is worth doing.

The appeal should specifically address:

• Why the preferred agent (Wegovy/semaglutide) is not optimal for this specific patient
• Clinical evidence for tirzepatide's superior efficacy in patients with significant insulin resistance (cite SURMOUNT-2 data)
• The dual mechanism of action and why it's relevant to your metabolic profile

If you want to hedge your bets, have your doctor submit a PA for Wegovy simultaneously. That way if the Zepbound appeal fails, you're not starting from scratch.