Stop asking why you were denied. Ask for the document.
Your plan has a written criteria document listing numbered requirements, and it has a
record of which one it applied to you. You can ask for both. It is free, it usually works, and it is the
single highest-leverage move in this entire process.
The ERISA document right cited below is 29 CFR 2560.503-1 · last checked
2026-08-12
Why this changes the argument
Without the criteria document
You are arguing about whether you deserve a medication. That is subjective, unanswerable, and it
is the appeal that gets denied. There is nothing for a reviewer to check.
With it
You are arguing about whether a specific document satisfies criterion 3.b. That has a right
answer, and you can go get the evidence that produces it.
A reviewer working through a queue can approve the second one in ninety seconds because you did their
job for them. That is the whole mechanism.
The four things to ask for
Most people call and ask "why was I denied," and get the same sentence that was already in the letter.
Ask for documents instead, and ask for all four. They are different things.
The clinical criteria or coverage policy for anti-obesity medications, in effect on
the date of your determination. Ask for the version number and effective date.
The specific internal rule, guideline or protocol relied on in your determination,
referenced by your claim number. This is not the same as item 1. Item 1 is the general policy. Item 2 is
what they applied to you.
The plan document or Summary Plan Description, including the pharmacy section and
any exclusions. This is where you find out whether an exclusion actually exists as written, or whether
someone applied one that is not there. That happens.
The complete claim file, including the credentials of the reviewer who decided.
Why they have to answer
On a self-funded employer plan this is a right, not a favor. Under the Department of
Labor claims procedure regulation at 29 CFR 2560.503-1, a claimant is entitled, upon request and free of
charge, to reasonable access to and copies of all documents, records and other information relevant to
the claim, including the internal rules and criteria relied on in the decision. Citing
the regulation by number changes the tone of the response.
On marketplace and fully insured plans, parallel disclosure obligations apply, and most carriers
publish their clinical policy bulletins openly anyway. On Medicare Part D and Medicaid, the criteria are
usually on the plan's website already.
The letter
Copy this, fill in the brackets, send it. Keep proof that you sent it.
REQUEST FOR PLAN DOCUMENTS AND CLAIM FILE
Member: [YOUR NAME] Member ID: [ID] Claim/Reference: [NUMBER]
Plan: [PLAN NAME] Plan sponsor: [EMPLOYER, if job-based]
Date: [TODAY]
To the Plan Administrator:
I am a participant in the above plan. On [DATE OF DENIAL] I received an adverse benefit
determination regarding [DRUG AND STRENGTH], reference [NUMBER].
Under the Department of Labor claims procedure regulation at 29 CFR 2560.503-1, a claimant
is entitled, upon request and free of charge, to reasonable access to and copies of all
documents, records, and other information relevant to the claim. I request the following:
1. The clinical criteria, coverage policy, or medical policy applied to this determination,
including the version number and effective date.
2. Any internal rule, guideline, protocol, or other similar criterion relied upon in making
the determination, as referenced in the notice.
3. The complete claim file for reference [NUMBER], including all records considered,
generated, or relied upon.
4. The professional qualifications and credentials of each individual who reviewed the claim.
5. The plan document and the Summary Plan Description in effect on [DATE OF DETERMINATION],
including the pharmacy benefit provisions and any exclusions applicable to this request.
6. A statement of the plan's internal appeal levels, whether each is mandatory or voluntary,
and whether the plan is subject to the federal external review process.
Please send these to [ADDRESS] or [EMAIL]. If any item will not be provided, please state
which item and the basis for withholding it.
Sincerely,
[YOUR NAME]
[ADDRESS] ยท [PHONE]
cc: [CARRIER] Appeals Department, reference [NUMBER]
Not on a job-based plan? Delete the regulation citation in the second
paragraph and open item 1 with: "I am requesting a copy of the clinical criteria applied to this
determination and the specific rule relied upon, as referenced in your notice dated [DATE]."
What to do while you wait
Do not wait. Two things run in parallel:
Look for it publicly. Many carriers and pharmacy benefit managers publish their
criteria openly. Search the drug name plus "prior authorization criteria" plus your carrier or PBM name.
Save the PDF with its effective date.
Start gathering. The criteria pattern is consistent enough across payers that you
will almost never be collecting the wrong things: documented weights with dates, comorbidities with
their ICD codes, prior medications tried and what happened, and your pharmacy fill history.
When it arrives, read all three parts
Criteria documents almost always have an initial authorization section, an approval duration, and a
separate continuation of therapy section. Most people read the first and miss that the
renewal runs on a different standard, which is exactly the trap that produces
the renewal denial a year later.
Two things to check that most people miss entirely:
The BMI test is usually written against your baseline BMI, meaning before any
weight-loss drug therapy, not your BMI today. Cigna's policy says so in an explicit note; Aetna's says to
use the baseline at the start of any drug therapy.
The lifestyle-program requirement varies wildly. Across the payer policies we have
read in full it is six months, three months, or no stated duration at all. Do not accept anyone's blanket
claim about what "insurance requires."
If they will not send it
Log the refusal with dates and names, then escalate: ask for the denial of the document request in
writing, note the failure in your appeal as a procedural issue, and mention it in any state complaint. A
plan that denied you and then refused to say which rule it used has handed you an argument.
Want the editable version and your deadline tracked?
Give us an email and we will send the letter as an editable document, plus Module 0, a free ten-minute
walkthrough of what happened and what your rights are.
The letter above is complete and yours to use right now either way. This is for convenience, not a
gate.
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