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Wegovy (semaglutide) prior authorization denied appeal

GLP-1 for weight management

To appeal a denied prior authorization for Wegovy (semaglutide), file a written appeal within 180 days. The appeal must cite the insurer's clinical policy, include a letter of medical necessity from the prescriber, and document each criterion the policy requires. The most common winning evidence is documented prior therapy history and a specialist letter.

Typical PA criteria

  • BMI 30 or higher, or BMI 27 with a weight-related comorbidity
  • Documented 6-month lifestyle intervention
  • No personal or family history of medullary thyroid carcinoma

Why your PA was denied

  • Plan excludes weight-loss medications
  • BMI documentation missing
  • No documented lifestyle intervention
  • Step therapy with phentermine or orlistat required

Evidence that overturns the denial

  • ✓Charted BMI history with weights and dates
  • ✓Comorbidity diagnoses with ICD-10 codes (E11.x, I10, G47.33)
  • ✓Documented prior weight-loss attempts with outcomes
  • ✓Letter of medical necessity citing STEP trial outcomes

Many employer plans carve out anti-obesity drugs entirely. If the denial cites a plan exclusion (not medical necessity), an appeal will not overturn it; check the Summary Plan Description.

Draft a Wegovy (semaglutide) appeal letter

Free analysis identifies the cited policy and missing evidence. Then a finished letter that maps your chart to the criteria.

Draft my appeal letter

FAQ

Why was my Wegovy (semaglutide) prior authorization denied?+

The most common reasons are: Plan excludes weight-loss medications; BMI documentation missing; No documented lifestyle intervention. Your denial letter names the specific criteria you did not meet.

How do I appeal a Wegovy (semaglutide) denial?+

File a written appeal within 180 days that cites the insurer's clinical policy, includes a letter of medical necessity from the prescriber, and documents the criteria the insurer requires.

What evidence overturns a Wegovy (semaglutide) denial?+

Charted BMI history with weights and dates; Comorbidity diagnoses with ICD-10 codes (E11.x, I10, G47.33); Documented prior weight-loss attempts with outcomes.

What if the plan excludes Wegovy (semaglutide) entirely?+

Plan exclusions are different from medical-necessity denials. Check the Summary Plan Description. If the drug is fully excluded, an appeal will not overturn it; you may need a formulary exception or manufacturer assistance program.

Other drugs

Not legal or medical advice. This page is a self-help resource. You make your own decisions. Strip personal identifiers (name, date of birth, address, member ID) from any document before uploading or sharing. The information here summarizes commonly-published payer policies and federal rules; confirm against your specific plan document and the current denial letter before acting.