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Weight Loss

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9 steps to appeal a prior authorization denial for weight loss medication

Written by Brittney Bertagna

Published: May 22, 2024

Medically Reviewed by Goldina Erowele, PharmD, MBA

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The majority of weight loss medications require prior authorization before they’re covered by insurance. Prior authorization is a process where your insurance company evaluates the medical necessity and appropriateness of a specific treatment or medication. 

This step in the approval process helps determine if the treatment proposed by your healthcare team aligns with the insurance company’s coverage guidelines. But, just as claims must be approved, they can also be denied. 

This guide will walk you through the steps necessary to know how to appeal a prior authorization denial in the event that this happens to you. 

Ready to start on your weight loss journey? Klarity connects you with healthcare providers who specialize in weight loss and can walk you through the process of submitting a claim to insurance. 

Is weight loss medication right for you? Find a provider and find out.

How to appeal a prior authorization denial step by step

If your request for weight loss medication coverage was initially denied, you have the option to file an appeal. The ultimate goal of the appeal is to demonstrate that the requested medication is necessary for your health and well-being and should be covered by insurance.

With an appeal, you’re contesting the insurance company’s prior decision not to pay for the medications prescribed by your care team. To successfully appeal a claim, you must provide additional information that supports the medical necessity of the weight loss medication being requested. 

Step 1: Understand why your prior authorization was denied

Insurance companies are legally required to provide your healthcare provider with a detailed explanation of the denial, and the opportunity to speak directly with the claim reviewer. 

One common reason for denial is simple errors, such as misspelled names, incorrect insurance ID numbers, or inaccurate birth dates. While these errors can lead to a denial, they are usually easily corrected by contacting your insurance company and providing the correct information.

Insurance companies often have a formulary, which is a list of approved medications, and if the prescribed medication isn’t on that list, it may be denied. A medication that’s prescribed off-label, meaning it’s being used for a condition it isn’t U.S. Food and Drug Administration (FDA) approved for, may also be denied. 

If a medication is prescribed off-label, such as taking Ozempic for weight loss, insurance companies may deny coverage for the cost of that medication because it isn’t prescribed for its FDA-approved purpose. 

Medical necessity is another factor that insurance companies consider when reviewing prior authorization requests. If the treatment doesn’t meet the threshold for being medically necessary, it may be denied.

Step 2: Call and talk to your insurance company

Reach out to your insurance company and request the denial be reconsidered for medical necessity. You can typically find the customer service number on the back of your benefits card. 

By speaking directly with your insurance company, you can verify the reason for the denial and make sure that a simple error wasn’t the cause. This also provides you with additional information about how to tailor your appeal to maximize your chances of approval.

Step 3: Know you have the right to appeal

If your medication treatment for weight loss was denied, it’s important to know that you have the right to challenge the decision. Appeals can be filed by you or your healthcare provider. 

Step 4: Understand the prior authorization denial appeals process 

Each insurance company has its own rules regarding its specific appeals guidelines. This process usually involves 3 steps — a first-level internal appeal, a second-level internal appeal, and an external appeal.

An internal review is conducted “in-house” by the health insurance company. It’s a request to reconsider their previous decision. Once the internal appeals process has been exhausted, an external review process can take place. 

Depending on whether you have a fully-funded or self-funded insurance plan determines how external appeals are managed. 

Process for fully insured or group health insurance

For fully insured health insurance plans, your member handbook for your insurance plan will provide you with the information needed. 

Contact your Human Resources department or refer to your member handbook for the appeals process for internal and external appeals. There you will be able to find the information you need to appeal and the specific timelines to submit the information.   

Process if your employer is self-insured

If your employer is self-insured, external appeals are governed by state laws and regulations. You can check with the Employment Retirement Income Security Act set forth by the United States Department of Labor, Employee Benefits Security Administration, to learn more about your specific coverage. 

If your employer has a self-insured policy, they may be able to cover the cost if you make a compassionate appeal to them. If you’re comfortable sharing your health information with your employer, speak with your Human Resources department or benefits manager to see if they would be willing to make an exception.

Step 5: Talk to your doctor

Your provider’s office likely has experience dealing with prior authorization denials and can help you gather the needed information to support your case. Their office will review the information submitted to the insurance company to ensure that no pertinent details were omitted. 

Now is also a great time to discuss your claim with your healthcare provider openly and honestly, so they can offer any suggestions they think may increase your chances of approval.

Step 6: Gather the needed information for your appeal letter

A formal appeal letter must be sent to your insurance company to continue the appeal process. An appeal letter consists of additional information and supporting evidence to explain your request for reconsideration of a denied medical treatment or medication.

To strengthen your appeal, keep track of past treatments and outcomes. Include recent test results and information about whether previous treatments were effective and, if not, share symptoms that followed. This helps show that alternative treatments have been explored and failed to provide the desired results.

Step 7: Write your prior authorization denial appeal letter or ask your provider to

The prior authorization denial appeal letter can be written either by you or by your healthcare provider. Regardless of the option you choose, your appeal letter must be tailored to the specific reason the insurance company denied your request.

For example, if the reason for the denial is “not medically necessary,” review your member handbook to understand the health plan’s definition of medical necessity and provide the necessary information accordingly. 

Throughout the appeals process, it’s important to keep records of all communication with your insurance company, including the date, time, and details of each interaction. 

You can download a sample appeal letter from the Patient Advocate Foundation as a starting point. 

Step 8: Submit your appeal or have your provider submit it

Once you’ve gathered all the necessary information and supporting documents, it’s time to submit your appeal. 

Your provider can do it for you, or you can do it yourself.

If you decide to submit the appeal yourself:

  • Your denial letter should provide you with the address and/or fax number where you can send your appeal. Depending on your insurance company, you may be able to upload your appeal directly to their member portal. 
  • To make sure your appeal is received, use certified mail or have it tracked so that you can confirm it was delivered.
  • Follow up with your insurance company to make sure they received your appeal.

If your provider submits the appeal:

  • Depending on your provider, he or she may be willing to file the appeal for you.
  • It may be necessary to provide authorization to your insurance company if another person files for you. Check with your insurance company for details.  

Step 9: Don’t wait for a decision, follow up

Don’t hesitate to follow up with your insurance company since many have specific timelines that dictate when information must be submitted — missed deadlines can affect your appeal.

To help move things along, ask about the status of your appeal and if there’s additional information they need to expedite the process.

People fight prior authorization denials and win

Although winning an appeal isn’t guaranteed, it’s possible to appeal a prior denial and win — even if you have to appeal more than once. 

A number of people have successfully appealed prior authorization denials and shared their experiences on social media sites such as Reddit. These stories provide valuable insights into the real-life experiences of others who have navigated the complex insurance landscape before you.

Options if your prior authorization is repeatedly denied

If your insurance repeatedly denies your claims, it may be worth asking your healthcare provider about alternative solutions. 

You may ask your doctors about compounded drugs. These drugs are custom-made from pharmaceutical-grade ingredients to create a medication tailored to individual needs. Compounded medications are often more cost-effective than brand-name drug formulations and may even be covered by some insurance plans.  

You can ask your insurance company about any resources or programs that may lower the cost of your medications. This may include drug coupons from sites like GoodRx, Optum Perks, SingleCareRx, drugs.com, and WellRx, and manufacturer savings cards similar to Eli Lily’s Zepbound Savings Card program. 

Key takeaways

Your insurance company may deny you coverage for weight loss medication, but you can appeal the decision and potentially get the coverage you need. 

If you’re prior authorization is denied, contact your insurance company to discuss the denial and to gather insights on how to tailor your appeal to maximize your chances of a successful appeal.

While winning an appeal isn’t guaranteed, working with your healthcare team to navigate the appeal process can increase your chances of success. 

Ready to lose it, get an online weight loss prescription 

Take that first step towards achieving your weight loss goals! Get started today by connecting with a weight loss provider on Klarity

Sources

American Academy of Family Physicians Foundation, Precertification, Denials, and Appeals: Reducing the Hassles, Anthony N. Akosa, https://www.aafp.org/pubs/fpm/issues/2006/0600/p45.html

Cover My Meds, 7 Common Prior Authorization Hurdles and How to Overcome Them, Mar. 2022, https://insights.covermymeds.com/healthcare-technology/prior-authorization/common-prior-authorization-hurdles-and-how-to-overcome-the

GoodRx, Weight Loss Medications, https://www.goodrx.com/conditions/weight-loss/drugs

National Association of Independent Review Organizations, Know Your Healthcare Appeal Rights: A Q&A on the Health Insurance- Appeals Process for Consumers, https://www.nairo.org/assets/docs/NAIRO-QandA-Know-Your-Healthcare-Appeal-Rights.pdf

Obesity Action Coalition, Access to Care Resources- Appealing a Denied Prior Authorization, https://www.obesityaction.org/action-through-advocacy/access-to-care/access-to-care-resources/appealing-a-denial/

Reddit, Ozempic, 2024, https://www.reddit.com/r/Ozempic/comments/19fitck/i_am_a_prior_authorization_specialist_ama/

U.S. Food and Drug Administration, Human Drug Compounding, Jan. 2024, https://www.fda.gov/drugs/guidance-compliance-regulatory-information/human-drug-compounding#:~:text=Compounding%20is%20generally%20a%20practice,needs%20of%20an%20individual%20patient.

The information provided in this article is for educational purposes only and should not be construed as medical advice. Always seek the guidance of a qualified healthcare professional with any questions or concerns you have regarding your health.

How we reviewed this article: This article goes through rigorous fact-checking by a team of medical reviewers. Reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the author.

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