Who should file the appeal, the patient or the doctor?

Both, ideally. The patient files the member appeal, and the prescriber sends a letter of medical necessity.

Guide · Updated November 2026

GLP-1 Insurance Appeal Letter Template: Copy, Fill In, Send

Insurance denied your Wegovy, Zepbound, or Mounjaro prescription. That denial is not the end. In HealthCare.gov marketplace plans in 2024, [fewer than 1% of denied in-network claims were appealed](https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/), and insurers upheld 66% of the denials that were appealed, which means about a third were not upheld. This guide gives you a copy-paste appeal letter template, the documents to attach, and the deadlines that matter.

Before You Appeal: Read the Denial Letter

Your denial letter (or Explanation of Benefits) states the reason code. The appeal strategy depends on it:

Denial Reason	What It Means	Your Angle
Not medically necessary	Plan disputes you need it	Attach BMI history, comorbidities, doctor’s letter
Step therapy required	Try cheaper options first	Document past diet programs and any weight-loss medications you have tried
Prior authorization missing	Paperwork never filed	Ask your prescriber to file the PA, not an appeal
Excluded benefit	Plan does not cover weight loss drugs at all	Appeal is hard. Argue a covered indication or switch strategy
Quantity or dose limit	Plan caps the fills	Prescriber letter explaining the titration schedule

One of these is not like the others. If weight loss medication is an excluded benefit in your plan documents, an appeal rarely wins, and your energy is better spent on the routes in our copay card and assistance guide or an employer plea during open enrollment. For everything else, appeal.

The Two Levels of Appeal

These rules cover most private plans under federal law. Medicare Part D and Medicaid use their own appeal processes and deadlines, so follow the instructions in your denial notice.

Level 1, internal appeal. You (or your prescriber) ask the plan to reconsider. HealthCare.gov says you must file within 180 days (6 months) of the denial notice. The plan must finish within 30 days for a service you have not received yet, and faster in urgent cases.

Level 2, external review. If the internal appeal fails, you can ask for an independent external review of denials that involve medical judgment. HealthCare.gov says your insurer is required by law to accept the external reviewer’s decision.

Most people never appeal. In the KFF data above, fewer than 1% of denied claims were appealed.

The Appeal Letter Template

Copy this, replace the bracketed parts, and send it to the appeals address on your denial letter. Ask your prescriber to send a supporting letter too. HealthCare.gov suggests including additional information you want the insurer to consider, such as a letter from the doctor.

[Your name]
[Address]
[Member ID] | [Group number]
[Date]

[Insurance company name]
Appeals Department
[Address from your denial letter]

Re: Appeal of coverage denial for [medication name], claim/reference number [number from denial letter]

Dear Appeals Reviewer,

I am appealing your denial dated [date] of coverage for [medication name], prescribed by [prescriber name, credentials] on [date]. The denial letter states the reason as [quote the exact reason].

This medication is medically necessary for me. My relevant history:

1. My BMI is [number], documented on [date]. [If applicable: I also have the following diagnosed conditions: type 2 diabetes / prediabetes / hypertension / high cholesterol / sleep apnea, diagnosed on (dates).]

2. I have attempted the following supervised weight management approaches without lasting success: [list programs, medications, and date ranges. Examples: a 6-month medically supervised diet program in 2024, metformin from (date) to (date), a commercial program from (date) to (date)].

3. My prescriber has determined that [medication name] is the appropriate treatment based on my history and its FDA-approved indication: [quote the indication from the label, for example "to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition"].

My documented conditions match this FDA-approved use. I ask the plan to cover this medically necessary treatment.

I have enclosed: the denial letter, a letter of medical necessity from my prescriber, and my relevant medical records. Please reconsider this denial. If you uphold it, please provide the clinical criteria used, the credentials of the reviewer, and instructions for external review.

Sincerely,
[Your name]

What to Attach

The denial letter. Always include a copy.
A letter of medical necessity from your prescriber. Ask their office. Many offices have a standard template.
Records that prove the story. BMI readings over time, lab results (A1C, lipids), diagnosis codes, and documentation of past weight loss attempts.
The FDA indication. One line quoting the label indication. For example, the Zepbound label covers adults with obesity, or adults with overweight and at least one weight-related condition, and adults with obesity and moderate to severe obstructive sleep apnea. Mounjaro is approved for type 2 diabetes, not weight management, so do not quote a weight-management indication for it.

Deadlines That Matter

You typically have 180 days from the denial to file an internal appeal.
The internal appeal must be completed within 30 days for a service you haven’t received yet, and 60 days for one you already received, according to HealthCare.gov.
External review requests are due within 4 months after the final denial notice, and standard external reviews are decided no later than 45 days after the request.

Check your denial letter and plan documents. Some plans run shorter clocks.

If the Appeal Fails

Request the external review. It is independent of your insurer.
Ask your prescriber about an alternative the plan does cover. A different GLP-1 sometimes sits on a better tier. Our copay card guide covers what the manufacturer cards actually pay in 2026.
Compare cash-pay routes. Manufacturer direct programs and licensed telehealth providers are covered in our cheapest GLP-1 guide.
At open enrollment, compare every plan you are offered specifically on GLP-1 coverage.

FAQ

Does appealing actually work?

Sometimes. In KFF’s analysis of 2024 HealthCare.gov plan data, insurers upheld 66% of appealed denials, so about a third were not upheld. Fewer than 1% of denials were appealed at all. Results vary by plan and by reason for denial.

Who should file, me or my doctor?

Both, ideally. You file the member appeal with the template above, and your prescriber sends the letter of medical necessity. Ask their office directly.

Can I appeal if my plan excludes weight loss drugs entirely?

You can, but benefit exclusions are much harder to overturn than medical-necessity denials. If you have type 2 diabetes, ask your prescriber whether a GLP-1 approved for diabetes fits your situation, since diabetes coverage is usually not excluded.

What is an expedited appeal?

If the standard timeline would seriously jeopardize your life or your ability to regain maximum function, you can ask for an expedited appeal. HealthCare.gov says the decision must come as quickly as your condition requires and within 4 business days. Expedited external reviews are decided no later than 72 hours after the request.

Guides:

Tools:

GLP-1 Cost Estimator

What we checked

This AI-assisted public-source desk check reviewed HealthCare.gov pages on internal appeals and external review, KFF’s 2024 analysis of marketplace claim denials and appeals, and the Zepbound prescribing information on November 4, 2026. This is not a clinical review and it is not medical advice. Prices and policies change, so confirm them with the provider or your prescriber before you act.