Insurance denial appeal — letter template and strategy

If your insurance denies Wegovy or Zepbound coverage, here's a clinically-aligned appeal strategy.

First — understand the denial reason

• Excluded by plan (weight management not covered).
• PA criteria not met (BMI, comorbidity, lifestyle docs).
• Step therapy required (try cheaper drug first).
• Off-formulary.

Documentation for appeal

• BMI documentation across 2+ visits.
• At least one weight-related comorbidity (HTN, dyslipidemia, T2D, OSA, CVD).
• Documented lifestyle intervention attempts (typically 3–12 months).
• Citation of relevant clinical trials (STEP-1, SURMOUNT-1, SELECT for CV).
• Letter of medical necessity from prescribing clinician.

Letter template

To Whom It May Concern at [Insurance Plan]:

I am writing to appeal the denial of [Wegovy/Zepbound] for my patient [Name], policy [Number]. The patient has documented BMI of [X] and weight-related comorbidity [comorbidity]. Per the [SELECT trial / STEP-1 / SURMOUNT-1] evidence base, this therapy is indicated for cardiovascular event reduction / chronic weight management. Lifestyle intervention has been attempted for [N] months without adequate response. I respectfully request reconsideration based on medical necessity criteria.

Second-level escalation

External review (state insurance commissioner). Some states have helpful patient advocacy programs.