How to Appeal a GLP-1 Insurance Denial and Win

In my last post, I shared tips on navigating the insurance process, including Prior Authorization and Alternative Diagnoses.

However, insurers often deny claims upfront, hoping patients won’t challenge them. A study revealed that 69% of people denied insurance coverage were unaware they could appeal, and 85% never pursued it.

Getting approval for expensive GLP-1 medications is much more likely on the second or third attempt — if done correctly! Let’s go over the key factors for a strong appeal. Every case is unique, but I’ll cover the key points.

Step-by-Step Guide to Appealing

When your insurance denies coverage, they must provide a written explanation outlining the reason for denial and the steps to appeal. You have up to six months from the denial notice to file your appeal.

STEP 1: Understand Why Your Insurance Denied Coverage

Check the denial response to identify the reason — it’s often referred to as the “Explanation of Benefits” in the insurance lingo. Common reasons include:

• Missing Documentation & ICD-10 Codes: Doctor’s office may forget to include your full medical history, enter the wrong weight or omit a diagnosis. This is crucial if you need to meet a specific BMI or have a qualifying condition like prediabetes. Check with your doctor to ensure all necessary information was submitted, including your BMI before starting a GLP-1 (especially for renewal prior authorizations) — not just your current weight.

• Not on "Formulary": Your insurance doesn’t cover Wegovy or Zepbound because they aren't on its approved medication list. You may need to request a formulary exception to appeal the decision.

• Not “Medically Necessary”: Your insurance believes you don’t meet the BMI or health condition criteria. In this case, your doctor must request a peer-to-peer review, where they discuss your case directly with an insurance

  representative. This process takes time and may delay approval.

• Failure to Try “Step Therapy”: Many insurance plans require you to try lower-cost weight loss medications, like Phentermine, before they cover GLP-1s. Depending on your state, your doctor may be able to request a step therapy exception to skip this requirement.

• Required Enrollment in a Weight Loss Program: Some insurance plans require proof that you participated in a structured weight loss program before approving GLP-1 coverage. If denied for this reason, gather records of your past weight loss efforts, including:

  • Paid or supervised programs (Weight Watchers, Noom, etc)

  • Diets you’ve tried

  • Gym memberships, personal training or other fitness activities

  • Start/end dates and results of each attempt

  According to reports from other users, insurers often require 3–6 months of participation and proof that you didn’t lose a certain amount of weight (1 lb per week). Understanding your plan’s specific requirements can help you build a stronger appeal.

Step 2: Gather Supporting Evidence

Below are the key areas to focus on with examples:

✔ Medical Conditions: Gather as much evidence as possible related to obesity-related health risks. Some individuals reported having cardiovascular issues, such as a history of high blood pressure, and provided prescriptions for statins to manage elevated cholesterol. In other case, a patient provided recent echocardiograms showing mild left ventricular hypertrophy.

For diabetes-related conditions, some presented HbA1c results of 7.5%, indicating prediabetes, along with prescriptions for Metformin to manage blood sugar. In a different case, a diagnosis of insulin resistance confirmed through lab tests.

✔ Think about Unique Personal Challenges: Document any physical, mental or personal circumstances that make weight loss more difficult for you.

Here are some common situations that may resonate with your own experience. Physical challenges like chronic knee pain from arthritis, which makes it difficult to walk long distances or run, are worth documenting. If you have asthma, you might mention how it worsens with exertion, making high-intensity workouts a challenge. For those who’ve had back surgery, noting how it limits participation in strength training or lifting exercises can be helpful.

Mental challenges also play a role — struggles with emotional eating due to depression or stress from work and personal life can lead to poor sleep and overeating, which are important to include as well.

✔ Non GLP-1 Weight Loss Medications: List any weight loss medications you've previously tried, along with any risks, side effects or contraindications you've experienced. If you haven’t attempted step therapy medications, work with your doctor to outline why these options are unsuitable for you in your appeal.

Examples: A patient reported taking Phentermine for 2 months in 2023, but experiencing insomnia and anxiety. Another case mentioned trying Orlistat for 4 months, but stopping due to gastrointestinal issues like diarrhea and bloating. Another example, a person used Contrave for 3 months, but had to discontinue due to severe headaches and dizziness.

✔ Weight Loss Attempts: As mentioned above, insurance representatives often prefer to see participation in a structured, paid weight loss program. However, all your efforts count. Gather evidence of past diets, gym memberships, personal training sessions, and any exercise activities you've tried or are currently doing. Be sure to include start and end dates, as well as the results of each program.

Some situations that might be relevant. A person tried the Keto diet in January 2024, losing 18 pounds in 3 months but gaining it back after 6 months. Someone else practiced intermittent fasting for 4 months, losing 10 pounds but facing issues with hunger and irritability. As for gym memberships, one individual had a gym membership from January to December last year, attending 3 times a week for 6 months and losing just 10 pounds. Another person swam twice a week for 4 months, gaining flexibility but not losing weight.

✔ Weight Trends: Provide an overview of your weight history over the past several years to illustrate long-term struggles and trends.

✔ Find academic research relevant to your case: Collect peer-reviewed clinical studies that support the efficacy and necessity of this medicine. Use reputable sources such as PubMed.gov to find relevant research.

Step 3: Draft Your Appeal Letter

Given that each person’s situation is unique, there’s no universal formula for crafting an effective appeal letter.

While many appeal templates are available online, I recommend writing your own to ensure it’s tailored to your specific situation.

For a well-structured letter, I recommend reading the official appeal guide from Eli Lilly.

Step 4: Submit Your Appeal

Make sure you know where to send your appeal and include the correct details in the header or cover sheet, usually found on your Explanation of Benefits or denial letter.

If submitting on your own, check the denial letter for the preferred submission method —some insurers accept online submissions, others require fax or mail.

If your doctor is submitting, review your letter and documents together to ensure consistency.

How long will it take to receive a decision on your appeal? The process typically takes between 30 and 60 days.

For your first attempt, try submitting the appeal yourself. Present your strongest case and ensure all key details are included.

If you’re denied again, consider using professional appeal services. Sometimes an expert is needed to overcome the hurdle. If you're looking for a reliable option, my recommendation would be Honest Care.

Remember, getting approved for GLP-1 after a second or third attempt is quite common.

Stay healthy (and hungry for knowledge),
Lucas Veritas