Ambetter (Centene marketplace) · Appeal · Updated May 25
Ambetter (Centene marketplace) appeal: 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 strategy: 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.
The appeal letter (copy and edit)
Copy the body below and paste it into your clinician's portal or word processor. Replace every [BRACKET] placeholder with patient-specific data. Attach the original denial letter, the original PA submission, and any new documentation that directly addresses the denial reason. The letter is from your clinician to the plan, signed by your clinician.
[Today's date] Ambetter (Centene marketplace) Prior Authorization Appeals Department Submitted via: Ambetter provider portal, CoverMyMeds or fax 1-866-685-8664 Re: APPEAL of prior authorization denial Patient: [Patient full name] Member ID: [Plan member ID] Date of birth: [Patient DOB] Original PA reference number: [Reference number from denial letter] Date of denial: [Denial letter date] Date of this appeal: [Today] To the Ambetter (Centene marketplace) Appeals Review Department, I am the treating clinician for [Patient name]. I am writing to formally appeal the denial dated [denial date] of my prior authorization request for [drug name] in the indication of [indication name]. The denial reason cited The denial cites: "BMI below the qualifying threshold". The plan's specific stated rationale was: [quote exact language from the denial letter]. This appeal directly addresses that specific reason. Clinical context [Insert 2-3 sentences summarizing the patient's clinical picture: BMI, age, comorbidities, prior treatment history and why this medication was prescribed.] Direct rebuttal to the denial reason The denial cites a BMI calculation below the qualifying threshold. The patient's current BMI, measured [date], is [value] at [height] / [weight]. This places the patient [at or above the 30 threshold for obesity indication / at or above the 27 threshold with documented comorbidity, which is (specific comorbidity with ICD-10)]. Updated measurement documentation is attached. The earlier BMI calculation the plan cited reflects a prior measurement that does not reflect the patient's current status. Patient-specific supporting findings - [Current weight, height, BMI with date measured] - [Comorbidity ICD-10 codes and the date each was documented] - [Prior treatment trials with dates and outcomes] - [Any lifestyle intervention documentation] - [Any specialty consultation supporting the requested treatment] Supporting evidence - STEP-1 enrollment criteria (BMI greater than or equal to 30, or 27 with one weight-related comorbidity) - SURMOUNT-1 enrollment criteria (same) - FDA labeling for Wegovy and Zepbound (BMI greater than or equal to 30, or 27 with comorbidity) Procedural points Per Ambetter (Centene marketplace)'s own appeals process, I am submitting this appeal within the 180 days from denial notice window from the denial notice. I am requesting: 1. A formal first-level internal appeal review of this denial 2. Written notification of the appeal decision within the statutory turnaround 3. If the denial is upheld at first level, automatic escalation to second-level internal review 4. If the denial is upheld at second level, external review per state insurance law I am available to discuss this case with the plan's medical director at [Prescriber phone] or [Prescriber email]. A peer-to-peer review is available at your request. Conclusion The patient meets the FDA-labeled criteria for this medication and indication. The clinical rationale is documented in the attached records. The denial reason cited does not reflect the documented clinical picture. I respectfully request that this denial be overturned and the prior authorization granted. Thank you for your attention to this appeal. Sincerely, [Prescriber full signature] [Prescriber printed name, credentials] [Prescriber NPI] [Practice name and address] Attachments: - Original denial letter - Original prior authorization submission - Updated patient measurements and labs - Documentation directly addressing the denial reason cited - All clinical records supporting the requested treatment
Evidence to cite in the appeal
- STEP-1 enrollment criteria (BMI greater than or equal to 30, or 27 with one weight-related comorbidity)
- SURMOUNT-1 enrollment criteria (same)
- FDA labeling for Wegovy and Zepbound (BMI greater than or equal to 30, or 27 with comorbidity)
The direct-rebuttal paragraph
The paragraph below is the heart of the appeal letter. It is what makes this appeal different from a generic re-submission. Adapt the bracketed clauses to the patient's specific findings.
The denial cites a BMI calculation below the qualifying threshold. The patient's current BMI, measured [date], is [value] at [height] / [weight]. This places the patient [at or above the 30 threshold for obesity indication / at or above the 27 threshold with documented comorbidity, which is (specific comorbidity with ICD-10)]. Updated measurement documentation is attached. The earlier BMI calculation the plan cited reflects a prior measurement that does not reflect the patient's current status.
Other appeal templates for Ambetter (Centene marketplace)
Same denial reason, other plans
Disclaimer
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.
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