Prior auth appeal letter that actually worked

Three denied claims later, I finally got my Wegovy approved. Here's what changed in the third appeal: my doctor submitted a peer-to-peer review request AND cited the plan's own coverage policy language directly in the appeal. Insurance companies are betting you'll give up. Don't.

Posting my insurance appeal letter since a few people asked. This is what finally worked after three denials: I had my doctor submit a Letter of Medical Necessity that specifically cited: (1) my BMI over 30 with comorbidities, (2) documented failure of two prior weight-loss interventions over 12 months, (3) relevant metabolic markers including elevated triglycerides and pre-diabetic A1C. The key addition that got it approved was asking the doctor to cite the specific plan coverage language and argue that denying the medication violated the plan's own obesity-management coverage terms. We also requested a peer-to-peer review call. Don't give up after one denial. Three denials is unfortunately normal. Each appeal should be more specific than the last.