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Independent · Updated May 25 · Not legal or medical advice

GLP-1 prior authorization appeal letters.

20 plans × 6 denial reasons = 120 appeal letter templates. Direct, evidence-based rebuttals to the most common denial reasons. The appeal success rate is much higher than first-pass approval because most denials cite a specific objection that can be directly rebutted with documentation you already have. Read the strategy for your denial reason, copy the letter, fill in patient-specific findings and have your clinician sign and submit.

Initial PA denials occur on roughly 40-60 percent of first-pass GLP-1 prior authorization submissions. Appeal success rates are far higher, often 60-75 percent for level-1 internal appeals and over 80 percent for level-2 or external review. The single most important variable: did the appeal letter directly rebut the specific denial reason cited in the denial letter.

Find my denial reason ↓First-pass PA letter library →

Pick your denial reason

Find the denial reason that matches the language in your plan's denial letter. Each reason has a specific rebuttal strategy and an appeal letter template tuned for each of the 10 major plans.

Denial reason
Step therapy requirement not met
Plan is requiring documented trial of phentermine, orlistat or another lower-cost agent before approving Wegovy or Zepbound.
Rebuttal: Rebut on one of three grounds: (1) prior trial of a step-therapy agent (often years ago, still counts), (2) documented contraindication to the step-therapy agent (cardiovascular disease for phentermine; malabsorption for orlistat) or (3) intolerance documented at any time. If none of those apply, the cheapest path is often to run a documented 4-12 week phentermine trial and re-apply rather than appeal.
Aetna→Cigna→UnitedHealthcare→Anthem Blue Cross Blue Shield→Blue Shield of California→Kaiser Permanente→Humana→Tricare→FEHB Blue Cross Blue Shield (Federal Employee Program)→Medicare Advantage (generic letter)→Independence Blue Cross→Highmark Blue Cross Blue Shield→CareFirst BlueCross BlueShield→Premera Blue Cross→Florida Blue→Horizon Blue Cross Blue Shield of New Jersey→Wellcare (Centene)→Molina Healthcare→Ambetter (Centene marketplace)→Oscar Health→
Denial reason
BMI below the qualifying threshold
Plan calculated BMI below 30 (or below 27 if the comorbidity pathway was requested) and denied on body composition grounds.
Rebuttal: Recompute BMI using a current measurement, not an old EMR entry. If current BMI is in fact below threshold, the appeal cannot win on this point and the indication should be reconsidered (T2D, OSA or CV indication pathways do not require an obesity-specific BMI). If current BMI is at or above threshold, attach the new measurement with the date and the device used.
Aetna→Cigna→UnitedHealthcare→Anthem Blue Cross Blue Shield→Blue Shield of California→Kaiser Permanente→Humana→Tricare→FEHB Blue Cross Blue Shield (Federal Employee Program)→Medicare Advantage (generic letter)→Independence Blue Cross→Highmark Blue Cross Blue Shield→CareFirst BlueCross BlueShield→Premera Blue Cross→Florida Blue→Horizon Blue Cross Blue Shield of New Jersey→Wellcare (Centene)→Molina Healthcare→Ambetter (Centene marketplace)→Oscar Health→
Denial reason
Insufficient documentation of weight-related comorbidity
Plan denied a BMI 27-29.9 patient because the comorbidity was not adequately documented in the submitted records.
Rebuttal: Pull the comorbidity ICD-10 from any prior visit in the patient's record (it does not need to be a recent visit). Cite the date of the visit and the diagnosis code. Attach the visit note or problem-list excerpt. If no comorbidity is in fact documented anywhere, the patient may need a new evaluation (sleep study for OSA, fasting lipid panel for dyslipidemia, ambulatory blood pressure monitoring for hypertension) and a re-submission rather than an appeal.
Aetna→Cigna→UnitedHealthcare→Anthem Blue Cross Blue Shield→Blue Shield of California→Kaiser Permanente→Humana→Tricare→FEHB Blue Cross Blue Shield (Federal Employee Program)→Medicare Advantage (generic letter)→Independence Blue Cross→Highmark Blue Cross Blue Shield→CareFirst BlueCross BlueShield→Premera Blue Cross→Florida Blue→Horizon Blue Cross Blue Shield of New Jersey→Wellcare (Centene)→Molina Healthcare→Ambetter (Centene marketplace)→Oscar Health→
Denial reason
Insufficient documentation of lifestyle intervention
Plan denied because the six-month dietary intervention or weight-management program participation is not documented.
Rebuttal: Lifestyle intervention is the most common denial reason because patients and clinicians under-document it. Self-reported diet attempts, gym membership, prior structured-program participation (Weight Watchers, Noom, hospital-based program) or prior anti-obesity medication trials all count toward this requirement. Attach any documentation that demonstrates six months of clinically supervised or self-directed weight loss effort.
Aetna→Cigna→UnitedHealthcare→Anthem Blue Cross Blue Shield→Blue Shield of California→Kaiser Permanente→Humana→Tricare→FEHB Blue Cross Blue Shield (Federal Employee Program)→Medicare Advantage (generic letter)→Independence Blue Cross→Highmark Blue Cross Blue Shield→CareFirst BlueCross BlueShield→Premera Blue Cross→Florida Blue→Horizon Blue Cross Blue Shield of New Jersey→Wellcare (Centene)→Molina Healthcare→Ambetter (Centene marketplace)→Oscar Health→
Denial reason
Drug not on formulary, plan excludes obesity drugs
Plan does not cover GLP-1 for obesity indication at all, either because the plan's employer carve-out excludes anti-obesity drugs or because the formulary class is excluded.
Rebuttal: Formulary exclusion is hard to appeal as obesity-indication. The realistic options are: (1) pivot to a non-obesity indication if the patient qualifies (T2D, OSA via SURMOUNT-OSA, CV indication via SELECT), (2) request a formulary exception with documented medical necessity or (3) explore patient-assistance programs and cash-pay alternatives. For Medicare patients, obesity-indication GLP-1 is excluded by federal statute (the 2003 Medicare Modernization Act), but T2D, OSA and CV indications are not.
Aetna→Cigna→UnitedHealthcare→Anthem Blue Cross Blue Shield→Blue Shield of California→Kaiser Permanente→Humana→Tricare→FEHB Blue Cross Blue Shield (Federal Employee Program)→Medicare Advantage (generic letter)→Independence Blue Cross→Highmark Blue Cross Blue Shield→CareFirst BlueCross BlueShield→Premera Blue Cross→Florida Blue→Horizon Blue Cross Blue Shield of New Jersey→Wellcare (Centene)→Molina Healthcare→Ambetter (Centene marketplace)→Oscar Health→
Denial reason
Not medically necessary (boilerplate)
Plan returned a generic medical-necessity denial with no specific clinical objection. This is the easiest denial to appeal because the plan has not articulated a defensible clinical reason.
Rebuttal: Boilerplate medical-necessity denials lose appeals at high rates because the plan must articulate a specific clinical reason on the second-level review. The appeal letter walks through the patient-specific clinical evidence, cites the registration trial for the indication and requests that the plan articulate the specific clinical basis for any continued denial.
Aetna→Cigna→UnitedHealthcare→Anthem Blue Cross Blue Shield→Blue Shield of California→Kaiser Permanente→Humana→Tricare→FEHB Blue Cross Blue Shield (Federal Employee Program)→Medicare Advantage (generic letter)→Independence Blue Cross→Highmark Blue Cross Blue Shield→CareFirst BlueCross BlueShield→Premera Blue Cross→Florida Blue→Horizon Blue Cross Blue Shield of New Jersey→Wellcare (Centene)→Molina Healthcare→Ambetter (Centene marketplace)→Oscar Health→

How appeals actually work

Most US health plans have three appeal levels: (1) first-level internal review, where a different clinician at the plan reviews the denial, (2) second-level internal review, usually by a panel including external clinicians, and (3) external review by a state- or federally-regulated independent review organization. Each level has a deadline; missing it is the single most common reason an appeal fails on procedure rather than merits.

For most GLP-1 denials, the first-level internal appeal is the one that matters. Most plans approve at this level if the letter directly rebuts the cited denial reason with patient-specific documentation. If the first level is upheld, second-level and external review are usually statutorily required by state insurance law, and at the external-review level the plan must defend the denial against an independent reviewer who applies the FDA labeling and the trial evidence.

Educational templates only. Educational templates only. Not legal or medical advice. Appeal letters must be signed by the treating clinician (MD, DO, NP, PA) with prescribing authority. Every plan reads the appeal carefully because the alternative is an external review the plan is statutorily required to lose if the evidence supports the patient. Address the specific denial reason in the first paragraph. Do not fabricate clinical findings.

John Samaras, editor of GLP Chart
John Samaras, Founder and editorI started GLP Chart after overpaying for a GLP-1 myself. Based in Austin, Texas. About this site · LinkedIn · Contact
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