Prior auth denied for the 3rd time - what am I doing wrong — January 2024

sarah.morrison said:

Denials are usually procedural rather than clinical, and the order that works reflects that.

sarah.morrison said:

...my insurance denied cost and coverage coverage because...

Insurance denial is the single biggest barrier to GLP-1 access. Let me share the appeal framework that worked for me and several community members:

1. Document medical necessity (BMI, comorbidities, failed alternatives)
2. Reference clinical practice guidelines (AGA, AACE, Endocrine Society)
3. Cite cost-effectiveness data (preventing diabetes/surgery saves money long-term)
4. Request peer-to-peer review between your doctor and the plan's medical director
5. File external appeal with your state insurance department if internal appeal fails

Don't accept the first denial. The appeal process exists for a reason.

A narrower follow-up, since the general answer is now clear:

How long did you give it before you decided it was working?

LabKate said:

sarah.morrison said: ...my insurance denied cost and coverage coverage because...

LabKate said:

...regarding the discontinuation data for cost and coverage...

I want to reframe the discontinuation narrative. We don't say "insulin fails because blood sugar rises when you stop it." We don't say "antihypertensives fail because BP goes up without them."

Why do we apply different logic to anti-obesity medications? The answer is stigma. We still, unconsciously, believe obesity is about willpower rather than biology. The discontinuation data actually PROVES it's a chronic biological condition requiring ongoing treatment.

This reframing isn't semantic — it has implications for insurance coverage, treatment duration, and patient expectations.

Reporting back.

Follow-up — getting the denial reason in writing was the step that mattered. It named the criterion, and the criterion was a document I already had.

Dr.NateNeph said:

LabKate said: ...regarding the discontinuation data for cost and coverage...

My insurance denied my PA related to cost and coverage. Has anyone successfully appealed? I'm considering going compounded instead.