How to Appeal a Zepbound Denial: Steps, Deadlines, and Your Odds

A Zepbound or other GLP-1 denial is appealed in two stages: first through the plan’s own internal appeal process, then, if the plan upholds the denial, through an external review by an independent decision-maker. For commercial and ACA plans, the rules require a written request for external review within 4 months of receiving the final denial notice, and a standard external review must be decided within 45 days ^[3][4]. Medicare Part D has its own five-level system that starts with a coverage determination, not an appeal ^[5]. Among Medicare Advantage denials that were appealed in 2024, 80.7% were partially or fully overturned ^[8], though only 11.5% of denied requests were appealed at all ^[8]. One caveat up front: the published denial and overturn rates come from data that excludes prescription drugs, so they describe the system generally, not GLP-1 outcomes specifically ^[7].

What kind of denial did I get?

Denials come in two broad flavors, and the difference shapes the whole strategy. The first is a benefit exclusion: the plan simply does not cover a category of treatment, such as drugs for weight loss, no matter the circumstances. The second is a medical-necessity or criteria denial: the drug is covered in principle, but the plan says its requirements were not met — for example, its rules on prior authorization or step therapy.

External review, the independent second stage, covers denials that involve medical judgment, including decisions based on the plan’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, as well as determinations that a treatment is experimental or investigational, and rescissions of coverage ^[3][4]. A blanket exclusion is a different animal: it is a statement about what the plan covers, not a judgment about the individual case. No published source states that external review reverses a benefit exclusion, so an exclusion denial is the harder road. Which kind of denial occurred determines the route, and the plan’s own documents are where its coverage terms and claims procedures appear ^[1].

A plan’s claims procedures, including any preauthorization or utilization review requirements, must be described in the summary plan description ^[1]. If the plan is a grandfathered plan, the internal appeal rules under 45 CFR 147.136 generally do not apply, and the external review provisions apply only to certain out-of-network emergency and air ambulance items ^[2] — so a grandfathered plan may offer fewer appeal rights.

What are my odds of winning an appeal?

Among denials that are appealed, a large share are overturned, but very few denials are ever appealed. In Medicare Advantage in 2024, insurers made 52.8 million prior authorization determinations, up from 49.8 million in 2023, and fully or partially denied 4.1 million requests — 7.7% of the total ^[8]. Only 11.5% of those denials were appealed, but 80.7% of appeals were partially or fully overturned ^[8]. That overturn rate is not a one-year fluke: in every year KFF examined, more than eight in ten appeals overturned the initial denial, and the appeal rate has risen from 7.5% in 2019 ^[8].

The first year of data under the 2024 CMS reporting rule, covering calendar year 2025 and posted by March 31, 2026, reports denial and overturn rates by market ^[7]:

Market (CY2025 standard requests)	PA denial rate	Share of denials overturned on appeal
Medicare Advantage	12%	67%
Medicaid managed care	14%	47%
ACA federally facilitated Marketplace	18%	43%

That KFF analysis drew on 14 insurers covering 25 million Medicare Advantage enrollees (69% of enrollment), more than 35 million Medicaid managed care enrollees (54%), and nearly 11 million ACA Marketplace enrollees (74%) ^[7]. Median response times ran about 1 day for standard requests, and about half a day for expedited Medicare Advantage requests ^[7].

Two big limits on these numbers. First, the reporting rule aggregates metrics for all medical items and services and excludes prescription drugs ^[7]. Second, the Medicare Advantage data are aggregated to the contract level, with no breakout by service type or plan ^[8]. No published source reports denial or appeal outcomes for GLP-1 drugs specifically, so these rates cannot be applied to Zepbound, Wegovy, or similar medications.

What rights do I have before I write anything?

The federal claims rules give protections that apply from day one. A plan may not charge a fee or impose costs as a condition of making a claim or appealing a denial — the rules treat that as unduly inhibiting claims ^[1]. A plan also cannot bar an authorized representative, such as a doctor, from pursuing a claim or appeal on a patient’s behalf ^[1].

If a pre-service claim is filed incorrectly, the plan must notify the claimant of the failure and the proper procedure within 24 hours for urgent-care claims, or within 5 days for non-urgent pre-service claims ^[1]. Plans must also have safeguards to verify that plan provisions are applied consistently to similarly situated claimants ^[1].

On the number of hoops: a group health plan may not require more than two appeals before a civil action can be brought under ERISA section 502(a) ^[1]. If a plan offers voluntary extra appeal levels beyond the required two, it cannot charge fees for them, limitations periods must be tolled while they are pending, the plan waives any argument that remedies were not exhausted by skipping them, and they must be offered only after the required appeals ^[1]. Mandatory arbitration of denials is prohibited unless it counts as one of the two appeals and does not block the right to sue under section 502(a) ^[1]. Note also that a rescission of coverage — cancellation based on a claim that false or incomplete information was given — counts as an adverse benefit determination with appeal rights ^[2][3].

What should I do first after the denial letter arrives?

The letter and the record contain three things that matter immediately. One: the final denial letter or the Explanation of Benefits (EOB) gives the contact information for the organization that handles the external review ^[3]. An unfavorable Medicare Part D coverage determination must likewise contain the information needed to file the next step, a redetermination request ^[6].

Two: the deadlines. The big one for commercial and ACA plans is the 4-month window to request external review after the final denial is received ^[3][4]. Medicare Part D has its own ladder of deadlines, covered below. For a Part D level 1 appeal, a request filed after the 65-day deadline must give a reason for filing late ^[5].

Three: the prescriber. In external review, after MAXIMUS receives the request and contacts the insurer, the insurer must send all documents related to the determination to MAXIMUS, the federal contractor, within 5 business days ^[4] — and additional information may be submitted for the reviewer to consider, as long as it arrives on or before the 4-month deadline ^[4]. The prescriber’s supporting statement is the centerpiece of that package for Medicare exceptions ^[5][6]. The clinical justification itself is the prescriber’s document to write; the record, the filing timing, and the channel are the other moving parts.

How does the internal appeal work for commercial and ACA plans?

The internal appeal is the plan reviewing its own decision. For group health plans, the rules cap the required internal appeals at two before a civil action can be brought ^[1]. The internal claims and appeals requirements sit in paragraph (b) of 45 CFR 147.136, with state external review processes in paragraph (c), the federal external review process in paragraph (d), and notice requirements in paragraph (e) ^[2].

The order of operations matters: internal appeal or appeals come first, then external review within 4 months of the final internal denial ^[3][4]. In some instances, a consumer may request external review at the initial adverse benefit determination, before completing internal appeals ^[4]. A plan’s specific procedures and timeframes are laid out in the summary plan description ^[1].

What is external review, and how do I file it?

External review hands the denial to an independent reviewer outside the insurance company. There are three possible routes: the state’s external review process, if it meets federal consumer protection standards; an accredited Independent Review Organization (IRO) that the insurer contracts with; or the HHS-Administered Federal External Review Process ^[3][4]. Which route applies depends on the plan and the state, which is why the denial letter’s contact information matters ^[3]. HHS maintains a state-by-state list of external review processes through its Center for Consumer Information and Insurance Oversight ^[3].

The mechanics under the HHS-administered process:

• A written request is due within 4 months of receiving the denial notice or final internal denial ^[3][4].
• Submission works by mail, fax, email, or the secure online portal ^[4]. MAXIMUS Federal Services contacts: online portal, phone 1-888-866-6205, fax 1-888-866-6190, email ferp@maximus.com, or mail to 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534 ^[3][4].
• After MAXIMUS receives the request and contacts the insurer, the insurer must send all documents related to the determination to MAXIMUS within 5 business days ^[4].
• Additional information may be added for the reviewer to consider, up to the 4-month deadline ^[4].
• A standard external review must be decided no later than 45 days after the request is received ^[3][4].
• An expedited external review must be decided no later than 72 hours after the request is received; an oral decision must be followed in writing within 48 hours ^[3][4].

A representative, such as a doctor or another medical professional who knows the condition, may be appointed to file the external review ^[3].

One time-sensitive notice: if the deadline to request external review fell between July 1, 2026 and August 3, 2026 and the plan uses the HHS-administered process, an extension until October 2, 2026 may be available. This may affect residents of Alabama, Florida, Georgia, Texas, Wisconsin, U.S. territories other than Puerto Rico, and people with state or local government plans in any state ^[3].

Who decides the external review, and is my insurer bound by it?

An independent reviewer — MAXIMUS under the HHS-administered process, or an accredited IRO under the contracting process — decides ^[3][4]. The decision is final and binding on both the claimant and the insurer: the insurer is required by law to accept the external reviewer’s decision ^[3][4]. Under the HHS-administered process, there is no further review after the decision is received, except that other remedies under federal or state law, such as filing a lawsuit, remain available ^[4].

The cost is capped. Under the HHS-administered process there is no charge at all ^[3][4]. If the insurer uses a state process or a contracted IRO, a charge is possible, but no more than $25 per external review ^[3].

How do I get an urgent or expedited decision?

Expedited tracks exist at every level. For external review, an expedited request is available when the standard timeframe would seriously jeopardize life, health, or the ability to regain maximum function; for expedited review of an initial determination, a request for an expedited internal appeal must also have been filed ^[4]. Expedited external reviews are decided within 72 hours ^[3][4].

In Medicare Part D, a request is expedited if the plan determines, or the prescriber tells the plan, that waiting for a standard decision may seriously jeopardize life, health, or the ability to regain maximum function ^[5]. Fast appeals are decided within 72 hours ^[5].

What if I have Medicare Part D coverage?

Part D has its own sequence, and it starts before any appeal: the coverage determination. The enrollee, the prescriber, or a representative can request one orally or in writing — by calling the plan, writing a letter, or using the CMS Model Coverage Determination Request form ^[5]. If the request is for payment back for a drug already bought, it must be in writing ^[5].

One distinction matters before any appeal: whether the request is actually an exception. A formulary exception is the request for when the drug is not on the plan’s formulary, or when a utilization management requirement is to be waived — step therapy, prior authorization, or a quantity limit. A tiering exception only asks for a non-preferred drug at preferred-tier cost sharing ^[6]. Exceptions are granted when the plan determines the requested drug is medically necessary for the enrollee, and the prescriber must submit a supporting statement ^[6].

Once a coverage determination or exception is denied, the five appeal levels run as follows ^[5]:

Level	Who decides	Time to file	Decision timeline
1. Redetermination	The plan	65 days from the initial denial notice	7 days standard benefit, 14 days payment, 72 hours fast
2. Reconsideration	Independent Review Entity	60 days	7 days benefit, 14 days payment, 72 hours fast
3. ALJ hearing	Office of Medicare Hearings and Appeals	60 days	Varies
4. Council review	Medicare Appeals Council	60 days after the ALJ decision	Varies
5. Federal court	Federal district court	60 days after the Council decision	Varies

For a level 1 redetermination, a request filed after the 65-day deadline must give a reason for filing late ^[5]. Level 3 carries a minimum amount in controversy — the figure shown on the Medicare.gov page is $180 for 2024 — and level 5 also carries a minimum amount in controversy, with the figure shown on the Medicare.gov page at $1,840 for 2024, and claims that may be combined to reach it ^[5]. These thresholds are adjusted annually, so check the current year’s amount before filing. An appeal should include the enrollee’s name, address, Medicare Number, the drug and the reasons for appealing, proof of any representative, and any supporting statement from the prescriber ^[5].

What makes a criteria denial reversible?

For Medicare Part D, the rules spell out what the prescriber’s supporting statement must say. For a formulary exception, it must indicate that the non-formulary drug is necessary because all covered Part D drugs on any tier would be less effective or would have adverse effects, or that the number of doses under a dose restriction has been or is likely to be less effective, or that a formulary alternative or step-therapy requirement has been or is likely to be less effective or to have adverse effects ^[6]. For a tiering exception, the statement must indicate that the preferred drug or drugs would be less effective, would have adverse effects, or both ^[6].

The prescriber can submit the statement verbally or in writing; if verbal, the plan may require written follow-up ^[5][6]. Once the plan receives the supporting statement, it must give written notice of its decision within 24 hours for expedited requests or 72 hours for standard requests, with a verbal notice allowed if written follow-up is mailed within 3 calendar days; payment requests involving exceptions get a decision within 14 calendar days ^[6].

For commercial plans, the analogous idea is showing that the denial turned on medical judgment — necessity, appropriateness, or effectiveness — because those are exactly the determinations external review covers ^[3][4]. The clinical argument itself is the prescriber’s document; the record, the timing, and the channel are the parts the patient controls.

Where can I get free help?

A state’s Consumer Assistance Program or Department of Insurance can help with filing internal appeals and external reviews ^[3]. The National Association of Insurance Commissioners maintains a state-by-state map as the directory for finding each state’s office ^[3].

Some states run their own review programs. California’s Independent Medical Review (IMR) program, created by the Legislature in 2001 and administered for CDI-regulated policies by the California Department of Insurance, provides an independent external review when a treatment has been denied as medically unnecessary or experimental/investigational ^[9]. State processes differ, so the final denial letter is the authoritative guide to which route applies ^[3].

What is the step-by-step checklist?

The sequence the rules set out:

1. Read the denial letter: the EOB or final internal denial gives the contact information for the organization handling external review ^[3], and an unfavorable Part D coverage determination must contain the information needed to file a redetermination request ^[6].
2. The plan’s claims procedures and deadlines appear in the summary plan description ^[1].
3. The deadlines that matter: 65 days for a Part D level 1 appeal, 60 days at each later Part D level, and 4 months for external review after a final internal denial ^[3][4][5].
4. The prescriber’s supporting statement anchors the package — verbal with written follow-up is acceptable for Part D exceptions ^[5][6].
5. Internal appeal or appeals come first; group health plans cannot require more than two ^[1].
6. If the plan upholds the denial, external review is filed within 4 months, using the contact information on the final denial letter ^[3][4].
7. Additional information for the reviewer is due on or before the 4-month deadline ^[4].
8. After MAXIMUS receives the request and contacts the insurer, the insurer must turn over all documents related to the determination within 5 business days ^[4].

No published source promises that an appeal reverses a plan exclusion, and none reports GLP-1-specific success rates. What the data do show is a system where most denials go unchallenged, and a large share of those that are challenged get overturned ^[7][8].

Sources

1. Legal Information Institute, Cornell Law School. 29 CFR § 2560.503-1 - Claims procedure.
2. Electronic Code of Federal Regulations. 45 CFR 147.136 - Internal claims and appeals and external review processes.
3. HealthCare.gov. Appealing a health plan decision: External review.
4. Centers for Medicare & Medicaid Services. HHS-Administered Federal External Review Process for Health Insurance Coverage.
5. Medicare.gov. Appeals in a Medicare drug plan.
6. Centers for Medicare & Medicaid Services. Exceptions.
7. KFF. Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain. August 13, 2026.
8. KFF. Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024. January 28, 2026.
9. California Department of Insurance. Independent Medical Review Program (IMR).
10. Pennsylvania Insurance Department. Request a Review If Your Health Insurance Denied a Treatment, Medication, or Service.
11. National Association of Insurance Commissioners. Prior Authorization White Paper. December 10, 2025.
12. Informed Plate. Prior Authorization for GLP-1 Obesity Medications: A Provider’s Guide.
13. Centers for Medicare & Medicaid Services. Medicare GLP-1 Bridge: Information for Providers.
14. Becker’s Payer Issues. Cigna defeats class action alleging GLP-1 coverage exclusions are disability discrimination. February 23, 2026.
15. Federal Register. Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2026. December 4, 2025.
16. Centers for Medicare & Medicaid Services. Third Level of Appeal: Decision by Office of Medicare Hearings and Appeals (OMHA).