What it means
The first step is usually an internal appeal, reviewed by the insurer itself. HealthCare.gov says you must file within 180 days of receiving the denial notice. The plan generally must decide within 30 days for a treatment you have not received yet, or 60 days for care already received. Urgent cases can be reviewed faster.
A strong appeal usually includes the denial letter, a letter of medical necessity from your prescriber, chart notes showing your BMI and weight-related conditions, and a reference to the plan's own coverage criteria and the drug's FDA-approved use.
If the internal appeal fails, you can usually request an external review by an independent party.
Ask your plan for the exact reason for denial in writing. Many denials are about missing paperwork, such as proof of a prior treatment, rather than a final judgment that you do not qualify.
Why it matters
Many GLP-1 coverage denials are overturned on appeal when the paperwork matches the plan's criteria.