Let’s Appeal / GLP-1 denials / Renewal denials

You lost the weight. Then you lost the coverage.

You met the criteria, got approved, did the work, and a year later the reauthorization came back denied because you no longer meet a BMI threshold. It reads like being punished for success. Usually it is a mechanical error, and the plan's own document is what proves it.

Verified against criteria documents from Aetna, Cigna, CVS Caremark, BCBS FEP and UnitedHealthcare, read in full · last checked 2026-08-12

What the letter usually says

Some version of: "Continuation of therapy criteria not met. Member no longer meets initial coverage criteria (BMI greater than or equal to 30, or greater than or equal to 27 with comorbidity)."

Read that again and notice what it actually says. It cites the initial coverage criteria. You are not making an initial request. You are making a continuation request. Those are two different standards in almost every criteria document ever written, and applying one to the other is an error you can name.

Open your plan's criteria document and look at its shape

Initial authorization

The BMI threshold, the comorbidity requirement, the documented lifestyle program, the step therapy. This is the gate to start. Approval typically runs 6 to 8 months.

Continuation of therapy

A different standard. Typically: have you lost at least 5% of baseline body weight, or maintained that loss? Approval typically runs 12 months.

The continuation standard generally does not re-ask the initial BMI question. Doing so would mean the drug is only covered while it is failing, which is not what anyone wrote down. So a renewal denial citing the initial criteria is frequently the wrong rule applied.

That is a procedural argument, and procedural arguments beat pleading. There is nothing for the plan to disagree with about how much you need the medication.

The second argument, and it is stronger. It hides in one word.

Go back to the initial criteria and read the BMI line slowly. In every commercial policy we have read in full, it is not written as "BMI ≥ 30." It is written as baseline BMI.

"At baseline, patient had a BMI ≥ 30 kg/m2 ... Note: This refers to baseline prior to any glucagon-like peptide-1 (GLP-1) agonist." Cigna, Weight Loss GLP-1 Agonists Prior Authorization Policy

"The patient has a baseline body mass index (BMI) ... NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy." Aetna, Zepbound PA with Limit 6192-C

Read that again, because it matters enormously. Even the initial criteria are not asking what your BMI is today. They are asking what it was before you started.

So a denial saying you no longer meet the BMI criterion because you are at 27.8 today is not just applying the wrong section. It is misreading the section it applied. Your baseline BMI was whatever it was, it is still that as a historical fact, and it always will be.

Two independent arguments, one letter

The continuation standard at section [Y] governs this request, not the initial standard at section [X], and I meet it.
Even under the initial standard at section [X], the test is baseline BMI, and my documented baseline BMI at initiation of therapy was [number] on [date].

Neither requires you to argue about need. Neither requires anything from your prescriber beyond a documented weight from the date you started.

The core of the letter

FIRST-LEVEL INTERNAL APPEAL, CONTINUATION OF THERAPY Member: [NAME] Member ID: [ID] Claim/Reference: [NUMBER] Drug: [BRAND] [STRENGTH] Date of denial notice: [DATE] Prior authorization period: [START] to [END] To the Appeals Department: I am appealing the denial of continued coverage for [DRUG] dated [DATE]. The denial states: "[VERBATIM REASON FROM YOUR LETTER]" 1. THE CRITERION APPLIED APPEARS TO BE THE INITIAL AUTHORIZATION STANDARD. The plan's clinical criteria document, version [X] effective [DATE], sets out initial authorization criteria at section [X] and a separate continuation of therapy standard at section [Y]. The determination cites the section [X] criteria. This request is for continuation of an existing authorization and is governed by section [Y]. 2. THE CONTINUATION STANDARD IS SATISFIED. Section [Y] provides: "[VERBATIM CONTINUATION CRITERION]" Documented baseline weight: [WEIGHT] on [DATE], source [DOCUMENT]. Documented current weight: [WEIGHT] on [DATE], source [DOCUMENT]. Change: [PERCENT]%, which meets the standard at section [Y]. 3. THE INITIAL CRITERIA, IF APPLIED, ARE ALSO SATISFIED. Section [X] is written against baseline BMI prior to any weight-loss drug therapy. My documented baseline BMI at initiation was [NUMBER] on [DATE]. I request that the plan overturn the denial and authorize continuation of therapy. Sincerely, [NAME] · [PHONE] Enclosures: A. Denial notice · B. Criteria document, sections [X] and [Y] C. Baseline weight documentation · D. Current weight documentation

Check your drug's actual threshold before conceding anything

The continuation bar is usually 5% of baseline, but it is not universal. UnitedHealthcare's policy uses 3% for Qsymia and 4% for Saxenda, reserving 5% for semaglutide, tirzepatide and the other appetite suppressants. If you came in just under 5% on an older agent, read your plan's actual number before you accept that you missed it.

Payer	Continuation standard	Duration
Aetna commercial	3 months at a stable maintenance dose, and ≥5% of baseline lost or maintained	12 months
Cigna national	≥5% of baseline body weight lost	1 year
BCBS FEP	≥5% lost or maintained, plus program participation and preferred products	12 months
UnitedHealthcare	Drug-specific: 3% Qsymia, 4% Saxenda, 5% Wegovy and others	12 months

Better than appealing: preempt it 90 days out

If you are currently covered, this is the section that saves you the whole ordeal.

Find your authorization end date. It is on your approval letter. If you cannot find it, call and ask: "What is the end date of my current authorization, and what are the reauthorization criteria?"
Get the continuation criteria in writing. Here is the letter that asks for them.
Make your baseline unambiguous in the record. The percentage is computed from it, so a wrong baseline produces a wrong answer.
Get a documented current weight at the office, not at home.
Ask the office to submit the reauthorization early. A lapse means an interruption even if you eventually win.

On the Medicare GLP-1 Bridge, none of this applies. An approved Bridge authorization runs through December 31, 2027 including refills and dose changes, with no annual reauthorization. The one thing that puts you back into the process is changing GLP-1s, which requires a new prior authorization, and the Bridge has no appeals process. Ask about the coverage consequence before the prescription changes, not after.

One thing we will not tell you. People ask whether they should regain weight to re-qualify. That is a medication and health question for your prescriber, not a coverage tactic, and we will not advise on it. If your plan's criteria genuinely exclude you at your current documented status, the honest path is a letter of medical necessity from your prescriber addressing maintenance and the clinical risk of discontinuation. Do not stop or change a medication on your own.

Read my renewal denial, free

It identifies which criterion they cited, computes your appeal deadline as a date, and tells you whether the wrong-section argument applies to your letter.

The full treatment, including the 90-day preemption checklist and the complete letter with every variant, is in The Denial Playbook: GLP-1 Edition. $99, and everything on this page is yours without it.