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Your appeal letter — SAMPLE (GLP-1 step-therapy)
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June 21, 2026
UnitedHealthcare Appeals Department
P.O. Box 6106
Cyprus, CA 90630
RE: Appeal of Adverse Benefit Determination — Denial ID: DN-44821
Member: Maria L. Hernandez | Member ID: UHC-8847291
Medication: Wegovy (semaglutide 2.4 mg injection) | Denial Reason: Step Therapy Not Satisfied
Dear UnitedHealthcare Appeals Department,
I am writing to appeal your adverse benefit determination dated June 1, 2026, which denied coverage for Wegovy (semaglutide 2.4 mg) on the basis that I have not satisfied your step-therapy requirement. I respectfully request that you reverse this determination and approve coverage for Wegovy as prescribed by my physician, Dr. Anita Sharma, MD, at Austin Internal Medicine Associates.
Under , I am entitled to a full and fair review of this denial. I am submitting this appeal within the required 180-day timeframe and request a response within 60 days as required by that regulation. I have satisfied or am exempt from your step-therapy requirement for the reasons set out below, and the denial is inconsistent with your own published coverage policy.
1. Prior Treatment History Satisfies Step Therapy
I have an established diagnosis of obesity (BMI 41.2, ICD-10: E66.01) documented in medical records from Austin Internal Medicine Associates dated January 14, 2026. Prior to Dr. Sharma's recommendation of Wegovy, I completed a structured, supervised weight-management program and a 12-week course of orlistat (Alli 60 mg tid), which I documented in my pharmacy records. I lost fewer than 3% of body weight over 12 weeks despite full adherence, and orlistat was discontinued due to adverse gastrointestinal effects that interfered with my daily functioning. Under , one documented prior pharmacotherapy trial is the standard step requirement, and I have met it.
2. Medical Necessity is Established by FDA Labeling and Clinical Guidelines
Wegovy is . My BMI of 41.2 places me well within the approved indication. The . I have hypertension (ICD-10: I10) and pre-diabetes (ICD-10: R73.09), documented in attached records.
3. Step-Therapy Exception Applies Under State Law
Even if your plan policy required additional steps, . My documented adverse reaction to orlistat and clinical failure satisfy the contraindication and prior-adverse-reaction prongs of the statutory exception. Denial of the exception under these facts is inconsistent with Texas law.
4. Requested Relief
I request that UnitedHealthcare: (1) approve Wegovy (semaglutide 2.4 mg, weekly injection) for a 12-month supply as prescribed; (2) confirm that prior authorization will be valid for at least 12 months to allow for dose titration; and (3) respond in writing within 60 days as required by .
Attached to this appeal: (1) Denial letter dated June 1, 2026; (2) Letter of medical necessity from Dr. Anita Sharma, MD, dated June 10, 2026; (3) Pharmacy records documenting orlistat trial and discontinuation; (4) Medical records reflecting BMI, hypertension, and pre-diabetes diagnoses; (5) Insurance card (copy).
I am willing to provide additional documentation at your request. Please direct any questions or communications to me at: [email protected] | (512) 555-0193.
Respectfully submitted,
[Signed electronically below]
Maria L. Hernandez
Member ID: UHC-8847291
Date of Birth: March 7, 1981
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