How to appeal a weight loss drug denial

A denial is a step in a process. Which body reviews it depends on who pays your claims, and the eight kinds of plan run to different forums on different clocks. This page gives the route for each one, with the federal rule that puts it there and a quote from that rule.

By the Covered Weight editorial team · Updated Aug 3, 2026. Research and sourcing by Evan Reid.

The order every route runs in

Almost every appeal runs the same three steps in the same order, and the plan type decides who performs the third one. Filing the third step before the second is finished is the most common way a reader loses a review that was available to them.

Step one
Read the notice, not a summary of it
The notice you received names the reason for the denial, the deadline for challenging it, and where to send the challenge. Every later step depends on those three facts, and no general page can supply them for your case.
Step two
Appeal to the plan that denied it
The first challenge goes back to the plan. It asks the plan to look again, usually against the written criteria the denial named, and it is the step that has to finish before anyone independent will take the case.
Step three
Ask the body that reviews your plan type
This is where the routes separate. A state insurance department, a federal review process, a Medicaid fair hearing and a Medicare redetermination are four different forums with four different rules, and the table below says which one is yours.

Where the appeal goes, by plan type

The left column is how a reader describes their own coverage. The middle column is the forum. The right column is the federal rule that puts it there, with the line it says it in, so you can read the rule rather than take our word for the route.

Appeal forum by plan type, with the federal rule behind each route
If your coverage is	The appeal goes to	The rule that puts it there
Self-funded employer planEmployer plan that pays its own claims	the plan's own internal appeal, then a federal external reviewEvery employee benefit plan must run an internal appeal process, and a plan not subject to a state external review process must provide the federal external review process instead.	Code of Federal Regulations, Title 29, Part 2560 (Rules and Regulations for Administration and Enforcement), Section 2560.503-1 Claims procedure, paragraph (h)(1) In general U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-29 issue date 2026-07-29 · Read Aug 3, 2026 Read the line this comes from Every employee benefit plan shall establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination Excerpt ends before the sentence continues "to an appropriate named fiduciary of the plan". Nothing inside the excerpt was altered. Code of Federal Regulations, Title 45, Part 147 (Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets), Section 147.136 Internal claims and appeals and external review processes, paragraph (d) Federal external review process U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026 Read the line this comes from A plan or issuer not subject to an applicable State external review process under paragraph (c) of this section must provide an effective Federal external review process Excerpt ends before the sentence continues "in accordance with this paragraph (d)". Nothing inside the excerpt was altered.
Fully-insured employer planEmployer plan bought from an insurance company	the insurer's internal appeal, then your state's external reviewThe plan and the insurer must run an internal claims and appeals process, and an independent external review follows it.	Code of Federal Regulations, Title 45, Part 147 (Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets), Section 147.136 Internal claims and appeals and external review processes, paragraph (b)(1) In general U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026 Read the line this comes from A group health plan and a health insurance issuer offering group or individual health insurance coverage must implement an effective internal claims and appeals process Excerpt ends before the sentence continues ", as described in this paragraph (b).". Nothing inside the excerpt was altered. Code of Federal Regulations, Title 45, Part 147 (Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets), Section 147.136 Internal claims and appeals and external review processes, paragraph (d) Federal external review process U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026 Read the line this comes from A plan or issuer not subject to an applicable State external review process under paragraph (c) of this section must provide an effective Federal external review process Excerpt ends before the sentence continues "in accordance with this paragraph (d)". Nothing inside the excerpt was altered.
Marketplace planA plan bought on the health insurance marketplace	the issuer's internal appeal, then your state's external reviewThe issuer must run an internal claims and appeals process, and an independent external review follows it.	Code of Federal Regulations, Title 45, Part 147 (Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets), Section 147.136 Internal claims and appeals and external review processes, paragraph (b)(1) In general U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026 Read the line this comes from A group health plan and a health insurance issuer offering group or individual health insurance coverage must implement an effective internal claims and appeals process Excerpt ends before the sentence continues ", as described in this paragraph (b).". Nothing inside the excerpt was altered. Code of Federal Regulations, Title 45, Part 147 (Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets), Section 147.136 Internal claims and appeals and external review processes, paragraph (d) Federal external review process U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026 Read the line this comes from A plan or issuer not subject to an applicable State external review process under paragraph (c) of this section must provide an effective Federal external review process Excerpt ends before the sentence continues "in accordance with this paragraph (d)". Nothing inside the excerpt was altered.
MedicaidMedicaid, including a Medicaid managed care plan	your plan's appeal if you are in managed care, then a state fair hearingA managed care enrollee may request a state fair hearing after the plan upholds its decision, and the state agency must grant a hearing to anyone who believes it acted wrongly on a claim for covered benefits.	Code of Federal Regulations, Title 42, Part 438 (Managed Care), Section 438.402 General requirements, paragraph (c)(1)(i) Authority to file U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-07-20 · Read Aug 3, 2026 Read the line this comes from An enrollee may request a State fair hearing after receiving notice under § 438.408 that the adverse benefit determination is upheld. Second sentence of paragraph (c)(1)(i). Nothing inside the excerpt was altered. Code of Federal Regulations, Title 42, Part 431 (State Organization and General Administration), Section 431.220 When a hearing is required, paragraph (a)(1) U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-07-20 · Read Aug 3, 2026 Read the line this comes from The State agency must grant an opportunity for a hearing to the following: (1) Any individual who requests it because he or she believes the agency has taken an action erroneously Two consecutive paragraphs joined by a single space: the (a) lead-in and item (1). The excerpt ends before the sentence continues ", denied his or her claim for eligibility or for covered benefits or services".
MedicareMedicare, including a Part D drug plan or a Medicare Advantage plan	a coverage determination from your plan, then a redetermination, then the federal appeal levelsA Part D plan sponsor must maintain appeal procedures for issues that involve coverage determinations.	Code of Federal Regulations, Title 42, Part 423 (Voluntary Medicare Prescription Drug Benefit), Section 423.562 General provisions, paragraph (a)(1)(iv) U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-07-20 · Read Aug 3, 2026 Read the line this comes from Appeal procedures that meet the requirements of this subpart for issues that involve coverage determinations. Item (iv) reads on from the lead-in at (a)(1), "A Part D plan sponsor, for each Part D plan that it offers, must establish and maintain".
TRICARE or VATRICARE or VA health care	the program's own appeal processThe VA medical benefits package covers prescription drugs available under the VA national formulary system, and a non-formulary request runs through the facility's own process rather than a state one.	Code of Federal Regulations, Title 38, Part 17 (Medical), Section 17.38 Medical benefits package, paragraph (a)(1)(iii) U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-38 issue date 2026-07-28 · Read Aug 3, 2026 Read the line this comes from Prescription drugs, including over-the-counter drugs and medical and surgical supplies available under the VA national formulary system. Item (iii) under "(1) Basic care". Nothing inside the excerpt was altered.
State employee planA state or local government employee health plan	the plan's internal appeal, then whichever external review the plan has adoptedA self-insured non-federal governmental plan may use the federal external review process, so the route is a question about the plan rather than about the state.	Code of Federal Regulations, Title 45, Part 147 (Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets), Section 147.136 Internal claims and appeals and external review processes, paragraph (d) Federal external review process U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026 Read the line this comes from A plan or issuer not subject to an applicable State external review process under paragraph (c) of this section must provide an effective Federal external review process Excerpt ends before the sentence continues "in accordance with this paragraph (d)". Nothing inside the excerpt was altered.
No planNo health plan right now	none, because there is no denial to appealAn appeal is a challenge to a plan's decision. With no plan there is no decision to challenge.	No published rule sets a forum here, because there is no plan decision to challenge.

This reads the appeal forum for each plan type for all 51 jurisdictions. A state insurance department reaches only the plan types a state regulates, which is why six of these eight rows name a federal body instead.

The deadlines are not on this page, and that is deliberate

Covered Weight publishes no appeal deadline for any plan type yet. Deadlines are set per jurisdiction and per plan, they are read one governing document at a time, and nothing appears here until it can be quoted with the document it came from.

The reason for the caution is specific to this fact. Most wrong numbers on a coverage site are recoverable: a reader calls the plan, gets the real answer, and is annoyed. A wrong appeal deadline is not recoverable. If a reader relies on it and files late, the right is gone and no correction on this page gives it back. So the honest version of this section is the one that sends you to the document that governs your case.

Take the deadline from your own notice. It is the document that decides your case, and a missed appeal deadline is not itself something you can appeal.

What an appeal file usually contains

An appeal is a documents exercise. The plan denied a request against written criteria, so the reply that works is the one showing those criteria being met, in the plan's own terms, with records from the people who treated you. The prescriber writes it. Your job is usually to make sure nothing on the list is missing.

The denial notice itself, including any reference or case number printed on it.
The criteria the plan applied, which the notice or the plan documents name.
The prescriber's letter, written against those criteria rather than in broad terms.
The records that evidence each requirement the criteria list.

What a plan requires varies by plan, so treat that as the shape of a file rather than a checklist for yours. The prior authorization documentation checklist sets out who supplies each item and where each plan type publishes the criteria.

When there is nothing to appeal

An appeal argues that the plan applied its own rules wrongly. When the plan document excludes weight treatment outright, the rule was applied correctly and the exclusion is the answer. That is a hard thing to read and it saves months: the useful next move is to find out whether the exclusion is really there, which for an employer plan means reading the plan document rather than the insurer's public policy.

Self-funded employer plans and weight treatment coverage explains why the insurer's name on your card does not tell you who wrote the rules, and what the treatment costs when no plan is paying covers the case where the exclusion holds.

Appeal routes by jurisdiction

Common questions

How long do I have to appeal?

Read the notice you received. It sets the clock for your case and it is the authority, not this page. Covered Weight does not publish a deadline for a plan type until it has read the governing document and can quote it, because a missed appeal deadline is a right nobody can give back to you.

Can I go straight to an independent review?

Usually not. An external review normally begins only after the plan has given its final answer on an internal appeal, and filing out of order can cost you the review. An urgent case is the exception, where the two can run at the same time. Your notice says which applies.

Why does the forum depend on my employer rather than my state?

Because federal law supersedes state laws that relate to an employee benefit plan. When an employer pays claims out of its own funds, a state coverage mandate and a state insurance department have no authority over that plan, so the review runs under federal rules instead.

Is a weight treatment denial worth appealing at all?

An appeal challenges whether the plan applied its own written rules correctly. When a plan excludes weight treatment outright, there is usually no criteria argument to make and the exclusion itself is the answer. When the plan covers it subject to criteria, the appeal is about whether the record shows those criteria being met.

Who publishes this, and are they a law firm?

Covered Weight is published by Amenti Labs LLC. It is not a law firm, an insurance broker, a healthcare provider, or a patient advocate you can hire, and it takes no fee from anyone for anything on this page. It reads published rules and shows what they say.

Documents this page reads

Code of Federal Regulations, Title 29, Part 2560 (Rules and Regulations for Administration and Enforcement), Section 2560.503-1 Claims procedure, paragraph (h)(1) In general
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-29 issue date 2026-07-29 · Read Aug 3, 2026
Read the line this comes from
Every employee benefit plan shall establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination
Excerpt ends before the sentence continues "to an appropriate named fiduciary of the plan". Nothing inside the excerpt was altered.
Code of Federal Regulations, Title 45, Part 147 (Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets), Section 147.136 Internal claims and appeals and external review processes, paragraph (d) Federal external review process
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026
Read the line this comes from
A plan or issuer not subject to an applicable State external review process under paragraph (c) of this section must provide an effective Federal external review process
Excerpt ends before the sentence continues "in accordance with this paragraph (d)". Nothing inside the excerpt was altered.
Code of Federal Regulations, Title 45, Part 147 (Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets), Section 147.136 Internal claims and appeals and external review processes, paragraph (b)(1) In general
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026
Read the line this comes from
A group health plan and a health insurance issuer offering group or individual health insurance coverage must implement an effective internal claims and appeals process
Excerpt ends before the sentence continues ", as described in this paragraph (b).". Nothing inside the excerpt was altered.
Code of Federal Regulations, Title 42, Part 438 (Managed Care), Section 438.402 General requirements, paragraph (c)(1)(i) Authority to file
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-07-20 · Read Aug 3, 2026
Read the line this comes from
An enrollee may request a State fair hearing after receiving notice under § 438.408 that the adverse benefit determination is upheld.
Second sentence of paragraph (c)(1)(i). Nothing inside the excerpt was altered.
Code of Federal Regulations, Title 42, Part 431 (State Organization and General Administration), Section 431.220 When a hearing is required, paragraph (a)(1)
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-07-20 · Read Aug 3, 2026
Read the line this comes from
The State agency must grant an opportunity for a hearing to the following: (1) Any individual who requests it because he or she believes the agency has taken an action erroneously
Two consecutive paragraphs joined by a single space: the (a) lead-in and item (1). The excerpt ends before the sentence continues ", denied his or her claim for eligibility or for covered benefits or services".
Code of Federal Regulations, Title 42, Part 423 (Voluntary Medicare Prescription Drug Benefit), Section 423.562 General provisions, paragraph (a)(1)(iv)
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-07-20 · Read Aug 3, 2026
Read the line this comes from
Appeal procedures that meet the requirements of this subpart for issues that involve coverage determinations.
Item (iv) reads on from the lead-in at (a)(1), "A Part D plan sponsor, for each Part D plan that it offers, must establish and maintain".
Code of Federal Regulations, Title 38, Part 17 (Medical), Section 17.38 Medical benefits package, paragraph (a)(1)(iii)
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-38 issue date 2026-07-28 · Read Aug 3, 2026
Read the line this comes from
Prescription drugs, including over-the-counter drugs and medical and surgical supplies available under the VA national formulary system.
Item (iii) under "(1) Basic care". Nothing inside the excerpt was altered.