Often enough to be worth an hour. Most GLP-1 denials are procedural — a BMI measured too long ago, a step drug the plan cannot see a record of, a request filed against the obesity indication when the patient also has sleep apnea. Those are fixed by documentation, not by argument. A denial that rests on the state genuinely excluding weight-loss drugs is the one that will not move, and this page tells you which of the two you have.

Is this legal advice?

No. It is a letter template filled in with what your state's Medicaid programme published, plus two federal rules that apply everywhere: the fair-hearing window and the continued-benefits rule. Your prescriber's chart notes do the clinical work; the letter's job is to point at the exact criterion and ask for a written answer.

Why does the letter ask them to state the criterion in writing?

Because a denial that names no criterion cannot be appealed properly, and asking forces the plan to commit to one. It also produces the document you need if the case goes to a fair hearing, where the question is whether the plan applied its own published rule.

Federal Medicaid rules give you at least 90 days from the date on the notice to request a fair hearing. If you request it within 10 days, benefits you were already receiving continue while the hearing is decided — which matters if you are mid-titration. States may allow longer; none may allow less.

Does anything I type here get sent to you?

No. The letter is assembled in your browser from data already on the page. There is no account, no upload and no server call — which is deliberate on a page where the natural thing to type is a member ID and a diagnosis.

← Medicaid coverage by state

Appeal a GLP-1 denial, in your state's own words

The sentence that moves a prior-authorisation decision is the plan's own criterion quoted back at it. So this fills the letter from what your Medicaid programme published — the BMI threshold, the drug you have to try first, the continuation rule — rather than from a generic template that argues in the abstract.

No model writes any of it. Every clinical sentence is fixed text or a figure you typed, because a letter you sign is the last place an invented number belongs.

Your state

Medication

What the denial said

Is it prescribed for anything other than weight loss?

This is the single strongest argument available, and only your prescriber can make it truthfully. Coverage of these indications is mandatory in every state.

Documented BMI

Weight-related conditions

Your name

Member ID

Date on the denial notice

I am under 21

Nothing here is sent anywhere. The letter is assembled in your browser from what Connecticut publishes — there is no server call and no account.

Your letter

Built from your state's own criteria. Nothing in it is written by a model.

[Your name]
Member ID: [your member ID]
Re: Appeal of prior-authorisation denial for Wegovy
Denial dated: [date on the denial notice]

To the appeals department,

I am appealing the denial of coverage for Wegovy. I am asking for a full reconsideration, and if the denial stands, for this letter to be treated as a request for a fair hearing.

My documented BMI is recorded in the enclosed chart notes, measured by my prescriber. I am asking the plan to state the numeric threshold it applied, and to re-adjudicate the request against the measurement enclosed.

Please send the specific criterion relied on, and the clinical basis for the decision, in writing. I am enclosing my prescriber's chart notes in support.

Under federal Medicaid rules I have at least 90 days from the date of the notice to request a fair hearing, and where I request one within 10 days of the notice my existing benefits continue while it is decided. I am asking that both rights be honoured here.

The criteria referred to above are the plan's own, published in Connecticut DSS Provider Bulletin 2025-31: GLP-1 diagnosis requirement, and coverage of phentermine and orlistat (https://www.ctdssmap.com/CTPortal/Information/Get-Download-File?Filename=pb2025_31.pdf&URI=Bulletins/pb2025_31.pdf).

Thank you for reviewing this.

[Your name]
[Date]

Before you send it

Attach your prescriber's chart notes. A letter without them is an assertion; with them it is a record the plan has to answer.
Check the date on the denial notice — the 90-day clock runs from it, not from when you opened the envelope.
If you are mid-treatment and want your supply to continue, the request has to go in within 10 days.
This covers Medicaid. Employer and marketplace plans run on different clocks — 180 days for the internal appeal, four months for external review — and the letter's state-criteria paragraph does not apply to them.

What your own plan publishes

An appeal is judged against the criteria the plan wrote, not against a general rule. Each of these sets out what that payer asks for, which document settles it, and where its published policy is.

Medicare →UnitedHealthcare →Blue Cross Blue Shield →Kaiser Permanente →Aetna →Cigna →Humana →TRICARE →VA health care →

Which approval a weight-loss exclusion cannot reach — a plan that excludes obesity treatment may still cover the same drug under its cardiovascular or sleep-apnea indication.

The criteria this fills from

Read from each programme's own published document, with the date on it. The other 29 programmes are on the coverage page with what is known about each.

Questions

Does appealing work?: Often enough to be worth an hour. Most GLP-1 denials are procedural — a BMI measured too long ago, a step drug the plan cannot see a record of, a request filed against the obesity indication when the patient also has sleep apnea. Those are fixed by documentation, not by argument. A denial that rests on the state genuinely excluding weight-loss drugs is the one that will not move, and this page tells you which of the two you have.
Is this legal advice?: No. It is a letter template filled in with what your state's Medicaid programme published, plus two federal rules that apply everywhere: the fair-hearing window and the continued-benefits rule. Your prescriber's chart notes do the clinical work; the letter's job is to point at the exact criterion and ask for a written answer.
Why does the letter ask them to state the criterion in writing?: Because a denial that names no criterion cannot be appealed properly, and asking forces the plan to commit to one. It also produces the document you need if the case goes to a fair hearing, where the question is whether the plan applied its own published rule.
How long do I have?: Federal Medicaid rules give you at least 90 days from the date on the notice to request a fair hearing. If you request it within 10 days, benefits you were already receiving continue while the hearing is decided — which matters if you are mid-titration. States may allow longer; none may allow less.
Does anything I type here get sent to you?: No. The letter is assembled in your browser from data already on the page. There is no account, no upload and no server call — which is deliberate on a page where the natural thing to type is a member ID and a diagnosis.