Was your Wegovy or Zepbound denied? How do insurance appeals work?

What does the denial letter tell you?

The letter must give the specific reason, the plan rule behind it and how to appeal, and that reason decides what you do next.¹

For employer plans, federal rules list what a denial notice must contain:¹

• the specific reason, such as “not medically necessary” or “not covered by the plan”;
• the plan provision it relied on;
• any rule, guideline or criteria it used, or a statement that you can get a free copy;
• if information was missing, what is needed and why;
• how the plan’s appeal process works.

Read the reason before anything else. It usually falls into one of three groups:

1. Something was missing, such as a recent weight, a lab result or proof of a past program. The letter must say what.¹
2. Criteria not met, or not medically necessary. This is a judgment about your case, and it is what appeals and external review are built for.³
3. Not covered by the plan. If the plan excludes weight-loss drugs as a benefit, an appeal argues against the plan’s own terms. External review is for denials that involve medical judgment.³

In 2024 Marketplace plans, 9% of denied in-network claims were for a missing prior authorization or referral.⁴ Another 5% were for lack of medical necessity.⁴ Insurers don’t report which services were denied.⁴

Which appeal rules apply to your plan?

It depends on who runs your coverage: an employer, the Marketplace, Medicaid or Medicare each have their own steps, deadlines and independent reviewer.^1,2,8,12

Time limits count from the date on the denial notice or decision, as each source describes. Your letter gives the exact dates for your case. Checked Oct 14, 2026.

Your plan documents or HR can tell you if an employer plan is self-funded: the employer pays claims from its own funds.⁵ In 2025, 67% of workers with employer coverage were in such plans.⁵ TRICARE, the VA and federal employee plans have their own processes: see military and federal plans.

How does an internal appeal work?

You ask the plan, in writing, to look again; someone who didn’t make the first decision must review it, within set time limits.^1,2

1. 1Get the file. Employer plans must give you copies of documents and records relevant to your claim, free, if you ask.¹
2. 2Answer the reason. Send the plan’s form with your name, claim number and member ID, plus supporting papers such as a letter from your doctor.²
3. 3Mark it urgent if it is. If a doctor who knows your condition says a request is urgent, an employer plan must treat it as urgent.¹ In urgent cases that doctor can act for you without a form.¹
4. 4Wait for the decision. For a medicine you haven’t received yet, employer and Marketplace plans have up to 30 days.^1,2

Few people appeal. In Marketplace plans in 2024, people appealed fewer than 1% of about 85 million denied in-network claims.⁴ Insurers upheld 66% of the denials that were appealed.⁴

A strong appeal answers the reason in the letter, point by point. If the denial was about step therapy or an unlisted drug, see formulary exceptions and step therapy for what prescribers send. For what a prior authorization asks for, see prior authorization, step by step.

What is external review, and when can you ask for it?

An independent reviewer outside the insurer looks at the case, and the insurer must accept the decision; you have 4 months after the final internal denial to ask.³

• What it covers: denials that involve medical judgment, treatments judged experimental, and coverage cancelled for alleged false information.³
• How long: a decision within 45 days, or within 72 hours or less when it’s urgent.³
• Cost: free under the federal process run by HHS; other processes can charge up to $25.³
• Who runs it: your state’s process if it meets federal standards, otherwise HHS or an independent review organization the plan contracts with.³ Your Explanation of Benefits (the statement the plan sends after a claim) or final denial letter says which.³

For a refused drug exception, Marketplace plans have a faster route. An independent reviewer must decide within 72 hours, or 24 hours when the original request was urgent.⁶

External review is used even less than internal appeals. Marketplace enrollees filed at least 5,881 external appeals in 2024, 4% of the internal appeals the insurers had upheld.⁴

How do Medicaid appeals and fair hearings work?

If a Medicaid health plan denies your GLP‑1, you appeal to the plan first, then can ask your state for a fair hearing.^8,9

Federal law sets the pace for Medicaid drug approvals. A state prior authorization system must respond within 24 hours of a request.⁷ The usual 72-hour emergency supply doesn’t extend to drugs on the list states may exclude, which includes weight-loss drugs.⁷

• Appeal to the plan: within 60 days of the denial notice, by phone or in writing.⁸ The plan decides within 30 days, or 72 hours if expedited; either can be extended by up to 14 days.⁹
• State fair hearing: your state gives you 90 to 120 days after the plan’s decision to ask.⁹ If the plan misses its own deadlines, you can go straight to the hearing.⁸
• Hearing decision: ordinarily within 90 days. For a health plan member, that counts from the plan appeal, minus the days you took to ask for the hearing; otherwise, from your hearing request.¹¹
• Urgent cases: if the plan turns down a fast (expedited) appeal, the state must decide an expedited hearing within 3 working days of getting the case file from the plan.¹¹

A hearing can’t add a benefit your state has chosen to leave out: federal law lets states exclude drugs used for weight loss.⁷ Which states cover them is in Medicaid coverage by state.

How do Medicare drug plan appeals work?

Medicare drug plans have 5 levels of appeal; the first, a redetermination by your plan, must be requested within 65 days.¹²

You, your representative or your prescriber can ask.¹² The plan decides in 7 days, or 72 hours if waiting could seriously harm your health.¹² If it still says no, you have 60 days to go to an independent review entity.¹²

Part D plans can’t cover a GLP‑1 used only for weight loss: the law excludes those drugs from Part D.¹³ Medicare’s separate GLP‑1 Bridge runs outside Part D plan coverage.¹⁴ Covered uses, the 2027 price and the cap are in how Medicare covers GLP‑1s.

What should you ask the plan for?

Ask in writing for the exact reason, the criteria the plan used and your claim file, before you write your appeal.^1,3

1. The specific reason and the plan provision it relied on.¹
2. The criteria or guideline used to decide, which employer plans must give you free on request.¹
3. Your claim file: the documents and records relevant to your claim, also free.¹
4. The summary plan description, which explains how the plan works, its benefits and its limits. The plan administrator must give you a copy.¹
5. Who runs external review for your plan, which the final denial letter or Explanation of Benefits shows.³
6. How to ask for an urgent decision, if waiting could harm your health.^1,2,12

For help with an employer plan, the Department of Labor’s benefits advisors answer at 1-866-444-3272.¹

Questions people ask

How we researched this

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