Most denials are about paperwork and plan rules — not about whether you "qualify" as a person. Below are the five most common reasons, in plain language, and what to do next for each one.
Verified Aug 20, 2026
Quick answer: a denial is the start of a process, not the end of it. Every common denial reason has a specific next step — and many are resolved with one resubmission from your doctor's office.
This isn't a rare experience. A national KFF poll found that 56% of GLP-1 users describe the drugs as difficult to afford — including 27% who had insurance and still paid the full cost themselves, and 14% who stopped taking the medication over cost. The paperwork burden has also grown fast: among Medicare Part D plans covering semaglutide and tirzepatide, prior-authorization requirements stayed under 25% through late 2023, then jumped to roughly 83% by the third quarter of 2024.
Each one below is grounded in a published appeal decision or official program notice — real outcomes, not guesses.
1
Missing or incomplete documentation
The most common denial family. The request reached your plan without everything its reviewers needed — a recent BMI reading, weight history, records of related conditions, or notes on past treatment attempts. It usually means the paperwork was incomplete, not that you were judged as a person. Insurers are required to state the reason for a denial in writing, and the letter tells you exactly what was missing.
Next step: Ask your doctor's office to resubmit with complete clinical records. The denial letter lists what to include.
Plans steer members toward a preferred medication and deny the others unless there's a documented reason. This is real and current: since January 2025, MassHealth has covered Zepbound as its preferred GLP-1 for weight loss and denies Wegovy prior-authorization requests on that basis — published appeal decisions show exactly this outcome. Commercial plans do the same with step therapy: try (or rule out) the preferred drug first.
Next step: Ask what the preferred alternative is. If there's a medical reason it won't work for you, your doctor documents that and requests an exception.
“The appellant did not have a BMI of 30 or greater and did not have documented associated illnesses related to weight.”
Plans typically approve at BMI ≥30, or BMI 27–30 only with a documented weight-related condition — type 2 diabetes, hypertension, sleep apnea, and similar. The key word is documented: if a qualifying condition isn't in the records your doctor submitted, the reviewer can't count it, even if you have it.
Next step: Make sure qualifying conditions appear in the submitted records, with recent dates, before resubmitting or appealing.
Approval isn't permanent. Many plans re-review coverage periodically and require documented progress to continue — the VA's published criteria for Wegovy, for example, require documented weight loss of at least 5% from baseline for continued use. If a renewal request goes in without those numbers, coverage can stop even though nothing about your treatment changed.
Next step: Before your renewal date, have your doctor include baseline weight, current weight, and any improved health markers in the request.
Pharmacy benefit managers and state programs move drugs on and off preferred lists, and coverage you had can disappear on a date, not because of anything in your chart. Two recent examples: CVS Caremark removed Zepbound from its major commercial formularies on July 1, 2025 (and has announced its return as a preferred option in late 2026 — these lists move both ways), and Medi-Cal removed Wegovy, Zepbound, and Saxenda from weight-loss coverage effective January 1, 2026.
Next step: Ask what the covered alternative is, or have your doctor file a formulary-exception request with clinical documentation.
This page explains publicly available insurance processes. It is not medical, legal, or insurance advice. Coverage rules vary by plan and state — confirm details with your insurer and make treatment decisions with a licensed healthcare professional.