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 program 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.

The notice states your deadline, and it can be shorter than you expect. In a managed care plan — where most Medicaid members are — you have 60 days from the notice to appeal to the plan first, and a state fair hearing comes after its decision, within 120 days of it (42 CFR 438.402 and 438.408). Where the state made the decision itself, federal rules let it allow up to 90 days to request a fair hearing — a ceiling, not a minimum (42 CFR 431.221). Request review within 10 days of the notice and benefits you were already receiving continue while it is decided, which matters if you are mid-titration.

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-authorization decision is the plan's own criterion quoted back at it. So this fills the letter from what your Medicaid program 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 North Carolina 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-authorization 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.

The state's published BMI criterion is: 18 and over: 30 or more, or 27 or more with a weight-related comorbidity — hypertension, type 2 diabetes, obstructive sleep apnea, cardiovascular disease or dyslipidemia. 12–17: the 95th percentile for age and sex, or 30, or the 85th percentile with at least one severe weight-related comorbidity. Separately, 45 and over with established cardiovascular disease qualifies at 27. Baseline weight and BMI must be measured within 45 days of the request. My documented BMI is recorded in the enclosed chart notes, measured by my prescriber, and the documentation is enclosed so the plan can check it against that criterion. If the figure on file is older than the measurement enclosed, I ask that the current one be used.

For the record, the plan's own continuation rule is: 5% body weight loss for adults, 4% BMI reduction for adolescents, and it has to hold.

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.

I am filing within the deadline printed on the notice. Federal Medicaid rules give a managed care plan's member 60 days from the notice to appeal to the plan, and let a state allow up to 90 days to request a fair hearing on its own decision. Where I request review within 10 days of the notice, my existing benefits continue while it is decided, and I am asking that this be honored here.

The criteria referred to above are the plan's own, published in NC Medicaid Outpatient Pharmacy Prior Approval Criteria — GLP-1s for Weight Management (https://medicaid.ncdhhs.gov/media/15676/download?attachment=).

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 and the deadline on the denial notice — the clock runs from that date, 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 program's own published document, with the date on it. The other 29 programs 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 program 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?: The notice states your deadline, and it can be shorter than you expect. In a managed care plan — where most Medicaid members are — you have 60 days from the notice to appeal to the plan first, and a state fair hearing comes after its decision, within 120 days of it (42 CFR 438.402 and 438.408). Where the state made the decision itself, federal rules let it allow up to 90 days to request a fair hearing — a ceiling, not a minimum (42 CFR 431.221). Request review within 10 days of the notice and benefits you were already receiving continue while it is decided, which matters if you are mid-titration.
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.