Wegovy Insurance Denied? How to Appeal & Get Approved (Free Template)

Key Takeaways (Read This First)

• Wegovy is FDA-approved for chronic weight management (adults and teens ≥12) and for reducing major cardiovascular risk in adults with established CVD and overweight/obesity—cite this in your appeal. FDA Access Data+1

• Common denial reasons: “not medically necessary,” missing prior authorization, BMI/criteria mismatch, step-therapy requirements, or “cosmetic/weight loss exclusion.” Many plans still approve with complete documentation meeting their criteria. Louisiana Blue

• What wins appeals: charted BMI and comorbidities, failed weight-loss attempts, prior meds tried/failed, adherence plan, and your clinician’s rationale tying to the plan’s policy language + FDA indications. FDA Access Data+1

  

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  Deadlines matter: file your internal appeal within 180 days of the denial; if upheld, request external review—usually within 4 months—where an independent reviewer can overturn the plan. HealthCare.gov+1

• Medicare & others: After the 2024 FDA cardiovascular indication, Part D plans may cover Wegovy for members with established CVD and overweight/obesity (coverage varies by plan). Medicaid coverage for obesity treatment differs by state. KFF+1

Why Wegovy Gets Denied—and How to Counter It

1) “Not Medically Necessary”
Insurers often require ≥30 BMI, or ≥27 with weight-related conditions (e.g., HTN, dyslipidemia, OSA). Provide BMI history, comorbidities, and guideline-based rationale. Many payer policies mirror these thresholds; your clinician should quote the plan’s own policy section. Louisiana Blue

2) Missing/Incomplete Prior Authorization
Each plan’s checklist is different. Ensure the PA includes your BMI trend, comorbidity list, prior lifestyle attempts, and any trial/failure or contraindication of alternatives (e.g., orlistat, phentermine/topiramate, etc.). Louisiana Blue

3) “Weight-Loss Drugs Excluded”
A growing number of plans make medical-necessity exceptions, especially for members with CVD risk where the FDA indication now includes risk reduction—explicitly cite this updated labeling in your argument. U.S. Food and Drug Administration

4) Step Therapy Requirements
If your plan requires lower-cost options first, ask your prescriber to document prior trials, intolerance, or clinical inappropriateness and tie it to the plan’s criteria language. Louisiana Blue

5) Medicare/Medicaid Nuances
Part D plans may cover Wegovy for the CVD-risk-reduction indication; standalone “obesity treatment” coverage is still limited. For Medicaid, check your state policy or ask your plan for its Wegovy medical policy. KFF+1

Your Appeal Game Plan (Step-by-Step)

1. Read the denial letter and highlight the exact reason (policy section, missing info).

2. Request the plan’s clinical policy for Wegovy and the prior-authorization criteria—these are your checklist. Louisiana Blue

3. Assemble evidence (see checklist below) and book a quick appointment for your clinician’s supporting letter.

4. File an internal appeal (simple form or a letter) within 180 days. Include your doctor’s letter and exhibits. HealthCare.gov

5. If denied again, request external review within the required window (commonly 4 months). The plan must honor the independent reviewer’s decision. HealthCare.gov

Evidence Checklist to Attach

• Clinician letter addressing the plan’s denial reason point-by-point.

• BMI history and vitals (height/weight trend); identify comorbidities (e.g., HTN, OSA, dyslipidemia, prediabetes).

• Prior treatments: structured diet/exercise programs, prior anti-obesity or related meds—trial/failure or intolerance.

• Risk profile: if you have established CVD, cite the FDA cardiovascular indication for Wegovy. U.S. Food and Drug Administration

• Plan policy excerpts and your eligibility mapping line-by-line. Louisiana Blue

• Clinically relevant context: obesity’s health impact and your functional limitations. (CDC prevalence data can underscore medical seriousness.) CDC

Free Wegovy Appeal Letter Template (Copy & Personalize)

Subject: Appeal of Wegovy (semaglutide 2.4 mg) Denial — [Member Name, ID#, DOB]

To: Appeals Department, [Plan Name]

I’m appealing the denial dated [date] for Wegovy. The plan cited “[insert reason/criteria]”. I meet the plan’s medical-necessity standards and FDA-labeled indications for semaglutide 2.4 mg.

Clinical summary:

• Diagnosis & risks: I have [obesity BMI X or BMI 27–29.9 with comorbidities: list], documented in my chart (see Exhibits A–B).

• Prior therapy: I completed supervised lifestyle interventions and prior medications [list], with inadequate response or intolerance (Exhibit C).

• Medical policy alignment: Under [Plan Policy # / section], criteria require [quote]. My record shows I meet each element (see point-by-point mapping in Exhibit D). Louisiana Blue

• FDA support: Wegovy is FDA-approved for chronic weight management and for reducing major CV events in adults with established CVD and overweight/obesity. This directly addresses my risk profile. FDA Access Data+1

Given the above, Wegovy is medically necessary and consistent with evidence-based standards. Please overturn the denial and approve coverage. If you uphold the denial, treat this as my request for an expedited external review if eligible. HealthCare.gov

Sincerely,
[Your Name], [Member ID]
[Address] • [Phone] • [Email]
Attachments: Clinician letter; chart notes; BMI/vitals; prior therapy documentation; policy mapping; relevant literature.

Pro Tips from an Insurance Appeal Specialist

• Map criteria line-by-line. Your strongest exhibit is a table showing each plan criterion and exactly where it’s met in your chart. Louisiana Blue

• Quote the FDA label and CV indication. This counters “cosmetic/vanity” narratives and shows disease-risk reduction. FDA Access Data+1

• Watch the clock. Mark calendar reminders for the 180-day internal appeal window and the external-review deadline. HealthCare.gov+1

• Ask your doctor to sign. A concise, criteria-mapped physician letter materially raises success odds.

• Escalate smartly. If your plan is ERISA-governed (most employer group plans), note that decisions on internal appeals must be issued within specific timelines (often within 60 days if only one level of appeal). Legal Information Institute

Frequently Asked Questions

Will Medicare cover Wegovy?
Possibly—for members with established cardiovascular disease and overweight/obesity, because of the 2024 FDA CV indication. Coverage is determined by individual Part D plans; check your plan’s formulary and criteria. KFF

What if my plan excludes “weight-loss drugs”?
Appeal using the plan’s medical-necessity pathway and the updated FDA indication for CV risk reduction (if applicable to you). Many plans allow exceptions when criteria are met. U.S. Food and Drug Administration+1

How long do I have to appeal?
Typically 180 days to file an internal appeal; after a final denial, most people have 4 months to request an external review. HealthCare.gov+1

What evidence moves the needle?
BMI trend; comorbidities; failed prior treatments; doctor’s narrative tied to plan language; and FDA indications relevant to your case. FDA Access Data+1

Real-World Example (What Success Looks Like)

A 48-year-old with BMI 29.4, established coronary artery disease, and hypertension was denied for “weight-loss exclusion.” The clinician’s appeal mapped the plan’s criteria, cited the FDA cardiovascular indication, attached a cardiac risk summary, and documented trials of prior options. The plan overturned the denial at internal appeal level one. U.S. Food and Drug Administration

Sources

1. FDA Wegovy label (indications, dosing). FDA Access Data

2. FDA press release: CV risk-reduction indication (Mar. 8, 2024). U.S. Food and Drug Administration

3. Healthcare.gov: Internal appeals (180-day deadline). HealthCare.gov

4. Healthcare.gov: External review (4-month window; binding decision). HealthCare.gov

5. DOL/ERISA claims procedures (timelines). Legal Information Institute

6. CDC adult obesity prevalence (context). CDC

7. Example payer criteria for Wegovy (thresholds/requirements). Louisiana Blue

8. KFF: Medicare coverage pathway for Wegovy’s CV indication. KFF

9. HHS/ASPE brief: Part D coverage limited to FDA-approved indications (context). ASPE

Video Section (Helpful Walk-Throughs)

• “How to Appeal a Health Insurance Denial – Step by Step” (KFF/consumer explainer)

• “Understanding Prior Authorization for GLP-1 Medications” (clinician overview)

• “External Review: What It Is and How to Use It” (consumer rights explainer)

Final Thoughts

A Wegovy denial isn’t the end; it’s the start of a structured process you can win with the right evidence and the right citations. Keep your appeal focused on your plan’s criteria, the FDA-recognized indications, and clear documentation from your clinician. If internal review fails, use external review; many members are approved there.

Disclaimer

This article is for educational purposes only and is not medical, insurance, or legal advice. Coverage varies by policy and jurisdiction. Consult your clinician and, if needed, an insurance or ERISA attorney about your specific situation.