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Insurance appeals for a GLP-1: the records that help your case

A denial is not the last word. Most people never appeal — fewer than 1% of denied in-network claims on HealthCare.gov plans were appealed in 2024 — yet the process exists, has firm deadlines and turns on documents. Here is how it works for most US private plans, and the records that make an appeal stronger.

By the Cafeity teamUpdated 6 min read

The short answer

To appeal a denied GLP-1 claim, ask your plan for the reason and its written coverage criteria, then file an internal appeal within 180 days of the denial notice. Include the denial letter, a letter of medical necessity from your prescriber and records that answer each criterion: dated weights and BMI, related conditions, previous treatment and how you are doing on the medicine.1 If the plan upholds its denial, you can usually ask for an independent external review within 4 months.2

Timeline of an insurance appeal: a denial notice; 180 days to file an internal appeal, which the plan must decide within 30 days for care not yet received, 60 days for care already received or 4 business days if urgent; a final decision; then 4 months to request an external review, decided by an independent reviewer within 45 days or 72 hours if expedited, which the plan must accept.
Two clocks matter: 180 days from the denial to appeal, and 4 months from the final decision to ask for external review.Diagram: Cafeity, from HealthCare.gov.

Denials are common, and appeals are rare

KFF's analysis of 2024 data found that insurers selling on HealthCare.gov denied 19% of in-network claims — about 85 million. Consumers appealed fewer than 1% of those denials, and insurers upheld 66% of the denials that were appealed.3 Put the other way round, about a third of appealed denials were not upheld.

Those figures cover every kind of claim, not just medicines, and come from marketplace plans only. Still, they make two points: appealing is unusual, and it is not hopeless.

Start with the denial letter

The letter tells you what you are arguing against. Look for:

  • The reason. Common ones include "not medically necessary", criteria not met, a drug you must try first (step therapy), the medicine not being on the formulary, a quantity limit, missing paperwork, or the benefit being excluded from your plan altogether.
  • The policy it relies on. Ask for the plan's written coverage criteria for your medicine so you can answer them point by point.
  • The deadline and the address for appeals.

An exclusion — a plan that does not cover a type of medicine at all — is a different problem from criteria you have not yet documented. If your plan excludes weight-management medicines, ask your prescriber whether another approved use applies to you, and check your options at the next enrolment period.

What coverage criteria usually look at

Plans tend to build their criteria on a medicine's approved uses. The weight-management labels approve these medicines alongside a reduced-calorie diet and increased physical activity for adults with obesity, or with overweight and at least one weight-related condition. The semaglutide label also covers reducing the risk of major cardiovascular events in adults with established cardiovascular disease and obesity or overweight, and the tirzepatide label covers moderate to severe obstructive sleep apnoea in adults with obesity.45

On top of that, plans add their own rules: BMI thresholds, documented diet and activity programmes, medicines tried first, and a minimum response to renew. Only your plan's written policy says which apply to you, so get it before you write anything.

The records that help

Answer the plan's criteria with documents, one for each point.
RecordWhy it helpsWhere it comes from
Denial letter and Explanation of BenefitsStates the reason you must answer and the deadlineYour plan
The plan's written coverage criteriaLets you answer point by pointYour plan — ask for it
Letter of medical necessityYour prescriber explains why this medicine, for you, nowYour prescriber
Dated weight, height and BMIShows thresholds were met, and the trend since startingClinic records, your own log
Related diagnosesMany criteria depend on conditions such as type 2 diabetes, high blood pressure, sleep apnoea or heart diseaseClinic records, test results, sleep studies
Earlier weight-management attemptsAnswers "lifestyle tried first" criteriaProgramme records, your notes with dates
Medicines tried beforeAnswers step-therapy rulesPharmacy and prescriber records
Your treatment recordShows doses taken as prescribed, side effects and responseYour log, such as a one-page summary
Notes of every callDate, name, reference number and what was saidYou

HealthCare.gov's own list of what to include is similar: the Explanation of Benefits forms or letters, a copy of your appeal request, any documents with additional information, records of phone conversations with the insurer, and correspondence from your doctor.1

The process and the deadlines

  1. File an internal appeal within 180 days (6 months) of receiving the denial notice.1
  2. The plan must decide within 30 days for a service you have not received yet, or 60 days for one you already have. In an urgent case, the decision must come as quickly as your condition requires, and at least within 4 business days.1
  3. If it is urgent, you can ask for an external review at the same time as the internal appeal.1
  4. If the denial is upheld, file a written request for external review within 4 months of the final decision. A standard review is decided within 45 days and an expedited one within 72 hours, and your insurer is required by law to accept the reviewer's decision. It is free under the federal HHS-administered process; elsewhere the charge cannot be more than $25.2

These are the federal rules for most private plans. Medicare, Medicaid and some employer plans have their own processes; the denial letter should say which applies.

Writing the appeal letter

Keep it short, factual and organised around the plan's own criteria. A structure that works:

  1. Who and what: your name, member ID, claim or reference number, the medicine by generic name, and the date of the denial.
  2. What you are asking for: "I am appealing the denial of coverage for … and ask the plan to approve it."
  3. Why the decision should change: each criterion in turn, with the document that answers it.
  4. What is enclosed: a numbered list matching your documents.
  5. Contact details and your prescriber's details.

Send it in a way you can track, keep a copy of everything, and diary both deadlines.

At renewal time

Approvals are often time-limited, and a renewal can ask for evidence of response. A continuous record — doses, weight as a trend, side effects — makes renewals faster and appeals easier. See records for prior authorization renewals for what renewals tend to ask.

Keeping a record of it

Cafeity's Visit Summary turns any period of your log into one page: doses and adherence, the weight trend and total change, symptoms against doses, and notes for your prescriber. It is a record for your prescriber, not a claim form — Cafeity never sends anything to an insurer.

Cafeity Visit Summary set-up: a period picker (4 weeks, 3 months, 6 months, custom) and switches for medication and doses, weight trend, body measurements, symptoms, protein and energy, activity and sleep, and notes tagged for the prescriber.
The Visit Summary.
Cafeity weight screen showing a smoothed trend weight of 115.6 kg, down 5.5 kg since last week, with the note "Based on your recent rate. Not a prediction."
The weight trend and total change.

Screenshots: Cafeity for iPhone, version 1.1.

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Common questions

How do I appeal a GLP-1 insurance denial?
Get the denial reason and the plan's written criteria, then file an internal appeal within 180 days with a letter of medical necessity and records that answer each criterion. If the denial is upheld, request an external review within 4 months.12
How long does an insurance appeal take?
An internal appeal must be decided within 30 days for care you have not had and 60 days for care you have had, or within 4 business days if urgent. External reviews take up to 45 days, or 72 hours if expedited.12
Do appeals ever work?
In KFF's analysis of 2024 HealthCare.gov plans, insurers upheld 66% of appealed denials, so about a third were not upheld. Fewer than 1% of denied claims were appealed at all.3
What is a letter of medical necessity?
A letter from your prescriber explaining why a treatment is medically necessary for you, usually answering the plan's coverage criteria with your history and test results.
Does external review cost anything?
It is free under the HHS-administered federal process. If your plan uses an independent review organisation or a state process, the charge cannot be more than $25.2
Can Cafeity send my records to my insurer?
No. Cafeity makes a Visit Summary that you can give to your prescriber, who handles authorisations and letters.

Sources

  1. Internal appeals HealthCare.gov, US Centers for Medicare & Medicaid Services
  2. External review HealthCare.gov, US Centers for Medicare & Medicaid Services
  3. Claims denials and appeals in ACA Marketplace plans in 2024 KFF, 24 March 2026
  4. Semaglutide injection and tablets for weight management — US prescribing information DailyMed, US National Library of Medicine, version published 30 June 2026
  5. Tirzepatide injection for weight management and obstructive sleep apnoea — US prescribing information DailyMed, US National Library of Medicine, version published 2 September 2026

Written by the Cafeity team from the sources listed here. Figures from prescribing information are quoted as the label states them; trial results are averages from those trials, not predictions for any one person. This page has not yet been reviewed by a clinician — see the editorial policy for how pages are researched and corrected.