Prior authorization is the single biggest hurdle to accessing GLP-1 medications for weight loss. This bureaucratic process requires your doctor to prove medical necessity before insurance will cover your prescription. With approval rates varying from 40-70% on first submission, understanding how to build a bulletproof prior authorization request is essential for success.

Understanding Prior Authorization

What Is Prior Authorization?

Prior authorization (PA) is an approval process requiring your healthcare provider to demonstrate that a prescribed medication is medically necessary before your insurance will agree to cover it.

Why Insurers Require PA for GLP-1s

High cost: $900-1,500/month retail price
Off-label concerns: Ozempic approved for diabetes, often prescribed for weight loss
Step therapy requirements: Want to ensure less expensive options tried first
Budget management: Control utilization of expensive specialty drugs
Prevent inappropriate use: Ensure patients meet medical necessity criteria

Timeline Expectations

Standard review: 3-5 business days (sometimes up to 14 days)
Expedited review: 72 hours (requires medical urgency documentation)
Incomplete submission: Additional 5-7 days for resubmission
Appeal process: 30-60 days if initially denied

The Prior Authorization Package: What You Need

1. Completed PA Form

Your insurance company's specific form (varies by insurer).

Where to Find It

Insurance company website (Provider Portal section)
Call pharmacy benefits manager directly
Request from your doctor's office (they usually have templates)

Critical Fields

Patient demographics and insurance information
Diagnosis code (ICD-10): E66.9 (Obesity, unspecified) or E66.01 (Morbid obesity due to excess calories)
Medication details: drug name, strength, quantity, and days supply
Provider information and NPI number
Clinical justification section

2. Letter of Medical Necessity (LMN)

A detailed letter from your provider explaining why this medication is essential for your health.

Essential Components

Patient identification: Name, DOB, insurance ID
Diagnosis: Primary (obesity) and secondary (comorbidities)
Current BMI: With calculation shown
Weight-related comorbidities:
- Type 2 diabetes or prediabetes (with A1C if available)
- Hypertension (with BP readings)
- Dyslipidemia (with lipid panel)
- Sleep apnea (with sleep study results)
- Cardiovascular disease
- Fatty liver disease
Previous weight loss attempts:
- Diet programs with dates and results
- Exercise programs
- Behavioral counseling
- Previous weight loss medications
Why THIS medication: Specific to patient's situation
Expected outcomes: Clinical benefits beyond weight loss
Contraindications checked: No thyroid cancer history, etc.

3. Supporting Clinical Documentation

Required Documents

Recent office visit notes documenting:
- Current weight and BMI calculation
- Discussion of weight management
- Review of comorbidities
Weight history: Chart showing weight over past 6-12 months
Documentation of supervised weight loss attempts:
- Diet program enrollment records
- Nutritionist visit notes
- Behavioral therapy records
- Food logs or weight tracking records
Lab results:
- Recent metabolic panel
- A1C (if diabetic/prediabetic)
- Lipid panel
- Thyroid function tests

Optional But Helpful

Sleep study results (if sleep apnea)
Cardiology notes (if cardiovascular disease)
Previous medication trial documentation (if applicable)
Quality of life impact statement

Building a Strong Medical Necessity Case

The BMI Requirement

Most insurers follow FDA labeling:

BMI ≥30: Obesity alone (no comorbidities required)
BMI ≥27: Overweight with at least one weight-related comorbidity

If You're Borderline

Request recheck at different time of day (weight fluctuates)
Document highest recent weight if currently losing
Use multiple measurements over time
Note if BMI was previously higher

Demonstrating Failed Conservative Therapy

Insurers want to see you've "failed" less expensive interventions first.

What Counts as Conservative Therapy

Medically supervised diet (3-6 months documented)
Structured exercise program
Behavioral modification counseling
Commercial weight loss programs (Weight Watchers, Noom, etc.)
Previous prescription weight loss medications

Documentation Tips

Keep records of program enrollment
Document dates, duration, and results
Show compliance (attended sessions, tracked food, etc.)
Explain why previous attempts didn't produce lasting results

Highlighting Comorbidities

Weight-related health conditions strengthen your case significantly.

Most Compelling Comorbidities

Type 2 diabetes: Especially with suboptimal control (A1C >7%)
Prediabetes: A1C 5.7-6.4%, shows progression risk
Hypertension: BP consistently >130/80 despite medication
Sleep apnea: Diagnosed via sleep study
Cardiovascular disease: History of heart attack, stroke, etc.
Dyslipidemia: High cholesterol/triglycerides

How to Document

Include diagnosis codes for each comorbidity
Attach relevant lab results or test reports
Note current medications treating these conditions
Explain how weight loss would improve these conditions

Letter of Medical Necessity Template

Sample Letter Structure

Customize for your specific situation:

[Date]

[Insurance Company Name]
[Insurance Company Address]

RE: Prior Authorization Request for Wegovy (Semaglutide 2.4mg)
Patient: [Full Name]
Date of Birth: [DOB]
Policy Number: [Policy #]
Group Number: [Group #]

To Whom It May Concern:

I am writing to request prior authorization for Wegovy (semaglutide 2.4mg subcutaneous injection) for my patient, [Patient Name], who is under my care for obesity and related metabolic conditions.

PATIENT INFORMATION & DIAGNOSIS
[Patient Name] is a [age]-year-old [gender] with:
- Primary diagnosis: Obesity (ICD-10: E66.9)
- Current BMI: [##.#] (Height: [X'X"], Weight: [XXX] lbs)
- Secondary diagnoses:
  • Type 2 Diabetes Mellitus (E11.9) - A1C: [#.#]%
  • Essential Hypertension (I10)
  • Dyslipidemia (E78.5)

MEDICAL NECESSITY
Despite comprehensive conservative weight management efforts over the past [X] months, [Patient Name] has been unable to achieve sustainable weight loss necessary to improve their metabolic health.

Previous interventions include:
• Medically supervised calorie-restricted diet ([dates]) - Lost [X] lbs, regained within [timeframe]
• Structured exercise program ([dates]) - [Results]
• Nutrition counseling with Registered Dietitian ([dates])
• Behavioral therapy for lifestyle modification ([dates])

Current health status:
- Type 2 diabetes with suboptimal glycemic control despite maximum-tolerated oral medications
- Hypertension requiring [#] antihypertensive medications
- Elevated cardiovascular risk (10-year ASCVD risk: [X]%)

CLINICAL RATIONALE FOR SEMAGLUTIDE
Semaglutide has been shown in clinical trials to produce:
- Average 15-20% total body weight loss
- Significant A1C reduction (1.5-2% in diabetic patients)
- Cardiovascular risk reduction (SUSTAIN and SELECT trials)
- Improvement in obesity-related comorbidities

For [Patient Name], achieving 10-15% weight loss would be expected to:
- Improve glycemic control, potentially reducing diabetes medication burden
- Lower blood pressure, reducing cardiovascular risk
- Improve lipid profile
- Enhance overall quality of life and reduce long-term healthcare costs

SAFETY CONSIDERATIONS
I have reviewed contraindications. [Patient Name] has no:
- Personal or family history of medullary thyroid carcinoma
- Multiple Endocrine Neoplasia syndrome type 2
- History of pancreatitis
- Current pregnancy or pregnancy plans

CONCLUSION
Given [Patient Name]'s obesity with multiple serious comorbidities, failure of conservative therapy, and the strong evidence base for semaglutide's efficacy and safety, I believe this medication is medically necessary and appropriate. I request your approval for Wegovy to help this patient achieve meaningful, sustained weight loss and improve their overall health trajectory.

Please contact me at [phone] if additional information is needed.

Sincerely,

[Provider Name], MD
[Medical License #]
[NPI #]
[Contact Information]

Common Reasons for Denial & How to Prevent

1. Insufficient Documentation of Previous Attempts

Problem: Insurer says "no proof of failed conservative therapy"

Solution: Include detailed records with dates and outcomes
Letters from nutritionists, trainers, or weight loss programs
Food logs or weight tracking documentation
If truly no previous formal attempts, document barriers (lack of access, financial constraints)

2. BMI Below Threshold

Problem: BMI calculated as 26.8, needs 27+ for comorbidity criteria

Solution: Request recheck; weight fluctuates 2-5 lbs daily
Use highest documented recent weight
Note if patient recently lost weight (document previous higher BMI)
Ensure accurate height measurement (many adults measured incorrectly)

3. Missing Comorbidity Documentation

Problem: BMI 27-29.9 but comorbidity not adequately proven

Solution: Attach actual lab results, not just mention in letter
Include diagnosis dates and treatment history
Show progression or inadequate control despite current treatment

4. Contraindication Concerns

Problem: Insurer flags potential contraindication

Solution: Explicitly state you've reviewed and patient has no contraindications
If patient has controlled thyroid disease (not MTC), clarify this is not a contraindication
Address any red flags proactively in letter

5. "Not Medically Necessary" Denial

Problem: Generic denial without specific reason

Solution: Strengthen clinical justification
Emphasize comorbidity improvement potential
Cite clinical guidelines (AHA/ACC, Endocrine Society, etc.)
Include peer-reviewed evidence
Calculate long-term cost savings from improved health

Expediting Your Prior Authorization

When to Request Expedited Review

Severe comorbidities requiring urgent intervention
Rapidly worsening condition
Hospital discharge requiring immediate medication start
Prior medication failed and urgent replacement needed

How to Request

Provider must document medical urgency in PA request
Call insurance to verbally request expedited review
Reference specific medical urgency in LMN
Follow up within 24 hours to confirm expedited status

Working with Your Healthcare Team

What Your Doctor Needs from You

Complete insurance information (ID card copy)
Records of previous weight loss attempts (receipts, program materials, etc.)
Personal weight history documentation
Any relevant medical records from other providers
Commitment to follow up regularly if approved

What to Ask Your Doctor's Office

"Can you submit the PA this week?" (Don't assume it's automatic)
"What additional documentation would strengthen the request?"
"Will you include a letter of medical necessity?"
"When should I expect to hear back?"
"What's the plan if it's denied?" (Appeal strategy)

Office Staff Tips

Prior auth is usually handled by specific staff members (MA, PA coordinator)
Be kind and patient—they're submitting dozens of PAs daily
Follow up weekly if no update after standard review period
Offer to provide any additional information needed

After Submission: Tracking Your PA

How to Check Status

Call insurance pharmacy benefits line (number on ID card)
Provider can check via online portal
Some insurers send automated status updates

Status Definitions

"In process": Under review, wait for decision
"Pend": More information requested—act immediately
"Approved": You're cleared to fill prescription
"Denied": Proceed to appeal process

If Pended for More Info

Insurer will fax request to provider
Typical turnaround needed: 48-72 hours
Common requests: More recent labs, additional visit notes, clarification on previous attempts
Respond immediately to avoid denial for "failure to provide information"

Success Rates & Timeline Reality Check

Approval Statistics

First submission: 40-70% approval rate
After appeal: Additional 20-30% success rate
Second appeal: 10-15% success rate
Overall: ~60-75% eventually approved if persistent

Realistic Timeline

Week 0: Prescription sent, PA initiated
Week 1: PA submitted by provider
Week 2: Initial decision (approve, deny, or pend)
Week 3-4: If pended, additional info provided
Week 4-6: If denied, appeal filed
Week 8-10: Appeal decision

Total time from prescription to medication in hand: 2-10 weeks on average

Conclusion

While prior authorization can be frustrating, a well-prepared submission significantly increases your chances of approval. The key is comprehensive documentation: clear evidence of medical necessity, documented previous attempts, and a strong clinical justification from your provider. Work closely with your healthcare team, be proactive in gathering supporting documents, and be prepared to appeal if initially denied. With persistence and proper documentation, most patients who meet clinical criteria eventually secure approval.