GLP-1 Insurance Appeal Letter Generator

Appeal details

June 9, 2026

[Insurance Company Name]
[Appeals Department Address]

Re: Formulary exception appeal — Wegovy
Patient: [Patient name]
DOB: [DOB]
Member ID: [Member ID]
Denial Date: [Denial date]

To Whom It May Concern:

I am writing to formally appeal the denial of coverage for Wegovy (semaglutide 2.4mg) for my patient [patient name]. The denial cited "Not medically necessary" as the reason. I respectfully request reconsideration based on the following clinical justification.

1. CLINICAL JUSTIFICATION

Wegovy is FDA-approved for chronic weight management (BMI ≥30 or ≥27 with comorbidity) and cardiovascular event reduction (SELECT trial 2024). Patient meets clinical criteria per FDA prescribing label. Per AACE Comprehensive Clinical Practice Guidelines on Obesity (2016, updated 2022), ADA Standards of Care 2024, Wegovy is recommended for patients with the documented clinical profile. Denial of medically necessary therapy contradicts evidence-based guidelines.

2. PATIENT-SPECIFIC FACTORS

The patient meets clinical criteria for Wegovy based on the following documented factors:

• Body Mass Index (BMI): [BMI] kg/m²
• Documented comorbidities: [list patient comorbidities]
• Prior weight management therapies attempted: [list prior therapies tried]

3. REBUTTAL TO SPECIFIC DENIAL REASON

The denial reason cited was "Not medically necessary." This is addressed as follows: Wegovy is FDA-approved for chronic weight management (BMI ≥30 or ≥27 with comorbidity) and cardiovascular event reduction (SELECT trial 2024). Patient meets clinical criteria per FDA prescribing label. Per AACE Comprehensive Clinical Practice Guidelines on Obesity (2016, updated 2022), ADA Standards of Care 2024, Wegovy is recommended for patients with the documented clinical profile. Denial of medically necessary therapy contradicts evidence-based guidelines. The patient's clinical profile clearly meets FDA-labeled criteria for Wegovy, and treatment with this medication aligns with evidence-based clinical practice guidelines.

4. CLINICAL CONSEQUENCES OF NON-COVERAGE

Without access to Wegovy, the patient faces:
• Continued cardiometabolic disease progression
• Increased risk of complications associated with documented comorbidities
• Increased long-term healthcare utilization costs from preventable disease progression
• Foregoing FDA-approved therapy that addresses the patient's specific clinical need

5. SUPPORTING DOCUMENTATION ATTACHED

Per your appeals process, the following documentation is attached:
• Patient's recent clinic visit notes
• Documented BMI and vital signs trends
• Lab results (including A1C, lipid panel, kidney function)
• Documentation of prior weight management therapies and outcomes
• Specialty consultation notes where applicable

6. CONCLUSION

Wegovy represents the appropriate, evidence-based, FDA-approved therapy for this patient's clinical profile. Per AACE Comprehensive Clinical Practice Guidelines on Obesity (2016, updated 2022), ADA Standards of Care 2024, this medication is the recommended therapeutic option. I respectfully request reconsideration of this denial and approval of Wegovy coverage. I am available to discuss this case or provide additional documentation as needed.

Please contact me at [prescriber phone] or [prescriber email] if additional information is required.

Sincerely,

[Prescriber Name]
[Credentials]
NPI: [NPI number]

cc: Patient

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