Adding my success story: Anthem BCBS, denied twice, approved on appeal.
What made the difference for me was getting my cardiologist to write a supporting letter, not just my PCP. I have a history of MI, and my cardiologist wrote that GLP-1 therapy was medically necessary for secondary cardiac prevention, citing the SELECT trial showing 20% MACE reduction.
Anthem couldn't really argue with a cardiologist saying "this patient needs this drug to not have another heart attack." Approved in 5 days.
Lesson: if you have relevant specialists, get them involved in the appeal. A letter from a specialist carries more weight than one from a PCP alone.
roxy_nash, that's a fantastic point about specialist letters. My endocrinologist's letter was definitely what pushed mine over the edge too.
Summary of what works on appeals based on this thread:
- Address the insurer's specific denial criteria point by point
- Document supervised lifestyle modifications (dietitian, structured programs)
- Document prior medication trials with specific outcomes
- List all comorbidities with ICD-10 codes
- Cite clinical trial data (SELECT, STEP, SURMOUNT)
- Include specialist letter(s) of medical necessity
- Frame as chronic disease management, not elective weight loss
- Make the cost-effectiveness argument
Dr. Martinez — you're amazing for offering to review letters. This community is the best.
Pinning this thread. This is one of the most useful resources we've created as a community.
For anyone starting the appeal process, please also check our wiki page on insurance navigation — it has state-by-state resources for filing complaints with your Department of Insurance if internal appeals are exhausted.
Remember: you have the RIGHT to appeal, and insurers count on most people giving up. Don't give up.
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