Medicare Advantage (generic letter) prior authorization letter for MASH or NAFLD with obesity.

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]

Medicare Advantage (generic letter)
Prior Authorization Department
Submitted via: Plan-specific portal or CoverMyMeds

Re: Prior Authorization Request, Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide)
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 Medicare Advantage (generic letter) Prior Authorization Reviewer,

I am the treating clinician for [Patient name]. I am writing to request prior authorization for Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide) for treatment of MASH or NAFLD with obesity (ICD-10: K76.0, K75.81, E66.9).

Clinical justification

Metabolic dysfunction-associated steatohepatitis (MASH, formerly known as NASH) and non-alcoholic fatty liver disease (NAFLD) are common comorbidities in patients with obesity and T2D. Under all major plan PA criteria, MASH or NAFLD documented by imaging, FibroScan or biopsy qualifies as a weight-related comorbidity, opening the obesity pathway at BMI greater than or equal to 27. The ESSENCE trial (semaglutide 2.4 mg in MASH), reported at AASLD 2024 and published in NEJM 2025, demonstrated histologic MASH resolution without worsening fibrosis in 62.9 percent of treated patients versus 34.3 percent on placebo at 72 weeks. The SYNERGY-NASH trial (tirzepatide in MASH) reported similar histologic benefit at 52 weeks. AASLD 2024 practice guidance names GLP-1 RA as appropriate pharmacotherapy in MASH when obesity coexists.

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 Medicare Advantage (generic letter) policy

This request meets the criteria set out in Plan-specific Medicare Advantage formulary and PA criteria:

  - Current weight, height, BMI (BMI greater than or equal to 27 with MASH or NAFLD as the qualifying comorbidity)
  - MASH or NAFLD documented by FibroScan, ultrasound, MR elastography, MR-PDFF or liver biopsy
  - ICD-10 K76.0 (NAFLD) or K75.81 (MASH) attached
  - Most recent ALT, AST, GGT and lipid panel
  - Hepatology consult letter (strengthens but not always required)

Supporting evidence

The clinical case for Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide) in this indication is supported by the following registration trials and outcomes data:

  - ESSENCE (semaglutide 2.4 mg in MASH), Sanyal et al., NEJM 2025
  - SYNERGY-NASH (tirzepatide in MASH), Loomba et al., NEJM 2024
  - Newsome et al. 2021 (semaglutide in NASH, phase 2), NEJM

Plan-specific note

Medicare does not cover GLP-1 for obesity indication under federal statute (the 2003 MMA exclusion). For patients with documented type 2 diabetes, Medicare Advantage plans cover Ozempic and Mounjaro under the T2D indication. For patients with established cardiovascular disease and obesity or overweight, Medicare Advantage plans may cover Wegovy under the SELECT FDA-labeled cardiovascular indication (approved March 2024). For patients with moderate-to-severe obstructive sleep apnea and obesity, Medicare Advantage plans may cover Zepbound under the SURMOUNT-OSA FDA-labeled OSA indication (approved December 2024). The CV and OSA pathways follow FDA labeling and are evaluated against the plan's medical-necessity criteria for each indication.

Requested action

I am requesting prior authorization for Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide) 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

Metabolic dysfunction-associated steatohepatitis (MASH, formerly known as NASH) and non-alcoholic fatty liver disease (NAFLD) are common comorbidities in patients with obesity and T2D. Under all major plan PA criteria, MASH or NAFLD documented by imaging, FibroScan or biopsy qualifies as a weight-related comorbidity, opening the obesity pathway at BMI greater than or equal to 27. The ESSENCE trial (semaglutide 2.4 mg in MASH), reported at AASLD 2024 and published in NEJM 2025, demonstrated histologic MASH resolution without worsening fibrosis in 62.9 percent of treated patients versus 34.3 percent on placebo at 72 weeks. The SYNERGY-NASH trial (tirzepatide in MASH) reported similar histologic benefit at 52 weeks. AASLD 2024 practice guidance names GLP-1 RA as appropriate pharmacotherapy in MASH when obesity coexists.

ICD-10 codes to attach

• K76.0
• K75.81
• E66.9

Criteria checklist (what to attach with the letter)

1. Current weight, height, BMI (BMI greater than or equal to 27 with MASH or NAFLD as the qualifying comorbidity)
2. MASH or NAFLD documented by FibroScan, ultrasound, MR elastography, MR-PDFF or liver biopsy
3. ICD-10 K76.0 (NAFLD) or K75.81 (MASH) attached
4. Most recent ALT, AST, GGT and lipid panel
5. Hepatology consult letter (strengthens but not always required)

Supporting trials and evidence

• ESSENCE (semaglutide 2.4 mg in MASH), Sanyal et al., NEJM 2025
• SYNERGY-NASH (tirzepatide in MASH), Loomba et al., NEJM 2024
• Newsome et al. 2021 (semaglutide in NASH, phase 2), NEJM

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.

• MASH or NAFLD documented only by ALT elevation without imaging or biopsy
• Plan requires hepatology consult and only primary care submitted
• Plan classifies MASH as outside the qualifying comorbidity list; cite the AASLD 2024 guidance and the obesity-with-comorbidity policy section

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:

• 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 Medicare Advantage (generic letter)

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

Same indication, other plans

Same MASH or NAFLD with obesity indication, different plan-specific letter templates if your insurance is not Medicare Advantage (generic letter):

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