Aetna prior authorization letter for Post-bariatric weight regain.

The 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 before sending. The letter is from your clinician to the plan, signed by your clinician.

[Today's date]

Aetna
Prior Authorization Department
Submitted via: Availity provider portal or fax 1-877-269-9916

Re: Prior Authorization Request, Wegovy or Zepbound
Patient: [Patient full name]
Member ID: [Plan member ID]
Date of birth: [Patient DOB]
Group number: [Group number if applicable]
Prescriber: [Prescriber full name, NPI, DEA]
Prescriber contact: [Phone, fax, email]

To the Aetna Prior Authorization Reviewer,

I am the treating clinician for [Patient name]. I am writing to request prior authorization for Wegovy or Zepbound for treatment of Post-bariatric weight regain (ICD-10: Z98.84, E66.01).

Clinical justification

Bariatric surgery is durable for most patients, but 20 to 50 percent experience clinically significant weight regain over the long term. Post-bariatric GLP-1 use has growing evidence: the 2024 BARI-OPTIMISE trial (Wegovy in patients with post-bariatric weight regain) demonstrated 8.8 percent mean weight loss versus 0.5 percent for placebo over 16 weeks. Post-bariatric status (ICD-10 Z98.84) does not exclude a patient from anti-obesity pharmacotherapy under any major plan's PA criteria; the qualifying criterion is current BMI plus comorbidities, regardless of how the patient reached that BMI.

Patient-specific findings

  - [Insert current measurements: weight, height, BMI, blood pressure]
  - [Insert relevant lab values with dates: A1c, lipid panel, kidney function]
  - [Insert documentation of comorbidities with ICD-10]
  - [Insert documentation of prior treatment history, including any prior GLP-1 trials, anti-obesity medication trials or lifestyle intervention]

Criteria met per Aetna policy

This request meets the criteria set out in Aetna Clinical Policy Bulletin 0040 (Obesity Treatment) and 0040 (Anti-Obesity Medications):

  - Current BMI and the date measured
  - Type and date of prior bariatric procedure (Roux-en-Y, sleeve gastrectomy, gastric bypass, duodenal switch)
  - Documented post-surgical weight nadir and current weight to establish regain pattern
  - Comorbidity status (T2D, hypertension, dyslipidemia, OSA) using ICD-10 codes
  - Bariatric surgeon or obesity medicine specialist co-signing the letter when possible

Supporting evidence

The clinical case for Wegovy or Zepbound in this indication is supported by the following registration trials and outcomes data:

  - BARI-OPTIMISE (semaglutide 2.4 mg in post-bariatric weight regain), Mok et al. 2024
  - Pajecki et al. 2023 (liraglutide in post-bariatric regain)

Plan-specific note

Aetna requires documented BMI greater than or equal to 30, or BMI greater than or equal to 27 with at least one comorbidity (T2D, hypertension, dyslipidemia, OSA). Six months of documented dietary intervention. Aetna prefers Wegovy for obesity indication. Step therapy may apply (phentermine, orlistat tried first under some plan formularies).

Requested action

I am requesting prior authorization for Wegovy or Zepbound at the [insert starting dose] starting dose, with planned titration per FDA labeling. I am also requesting that this authorization be granted for a continuous 12-month period subject to documented clinical response, per standard formulary practice.

If additional information is required, please contact me directly at [Prescriber phone] or [Prescriber email]. I am available to discuss this case with your medical director if helpful.

Thank you for your attention to this request.

Sincerely,

[Prescriber full signature]
[Prescriber printed name, credentials]
[Prescriber NPI]
[Practice name and address]

Attachments:
  - Current vital signs and BMI calculation
  - Most recent relevant labs
  - Documentation of comorbidities
  - Documentation of prior treatment trials
  - Sleep study report (if OSA indication)
  - Cardiac history documentation (if CV indication)

Clinical rationale for this indication

Bariatric surgery is durable for most patients, but 20 to 50 percent experience clinically significant weight regain over the long term. Post-bariatric GLP-1 use has growing evidence: the 2024 BARI-OPTIMISE trial (Wegovy in patients with post-bariatric weight regain) demonstrated 8.8 percent mean weight loss versus 0.5 percent for placebo over 16 weeks. Post-bariatric status (ICD-10 Z98.84) does not exclude a patient from anti-obesity pharmacotherapy under any major plan's PA criteria; the qualifying criterion is current BMI plus comorbidities, regardless of how the patient reached that BMI.

ICD-10 codes to attach

• Z98.84
• E66.01

Criteria checklist (what to attach with the letter)

1. Current BMI and the date measured
2. Type and date of prior bariatric procedure (Roux-en-Y, sleeve gastrectomy, gastric bypass, duodenal switch)
3. Documented post-surgical weight nadir and current weight to establish regain pattern
4. Comorbidity status (T2D, hypertension, dyslipidemia, OSA) using ICD-10 codes
5. Bariatric surgeon or obesity medicine specialist co-signing the letter when possible

Supporting trials and evidence

• BARI-OPTIMISE (semaglutide 2.4 mg in post-bariatric weight regain), Mok et al. 2024
• Pajecki et al. 2023 (liraglutide in post-bariatric regain)

The denial reasons to preempt

Most denials of this combination cite one of the reasons below. Address each one in the patient-specific findings section before you send. If the plan denies anyway, the appeal letter cites the same evidence with the denial reason added in the opening paragraph.

• Current BMI is below 30 (and no comorbidity documented at BMI 27 to 29.9)
• Bariatric surgery history not documented
• Plan attempts to deny on grounds that the patient already received a definitive obesity treatment (this is rebuttable; weight regain is a recognized clinical entity)

If you have not picked a program yet

The PA path is faster when your prescriber is already familiar with your insurance plan and runs the authorization regularly. Programs in our chart that actively run prior authorization for Wegovy or Zepbound:

• PlushCare · commercial and Medicare PA experience
• Form Health · obesity-medicine specialty, high PA success rate
• Knownwell · cardiometabolic focus, all major PBMs
• Calibrate · insurance-focused, employer-friendly

Other indications under Aetna

If this indication is not the right fit, try a different qualifying indication under the same plan:

Same indication, other plans

Same Post-bariatric weight regain indication, different plan-specific letter templates if your insurance is not Aetna:

Disclaimer

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