Jul 22, 2024 at 11:00 PM#1
I see so many posts about prior authorizations taking weeks or getting denied multiple times. Mine was approved in under 24 hours and I want to share exactly what happened because I think the preparation made all the difference.
Insurance: UnitedHealthcare Choice Plus PPO (employer plan)
Medication: Zepbound 2.5mg starter
Timeline: PA submitted Tuesday 9:14 AM, approved Wednesday 8:47 AM
Here's what I did before even asking my doctor to submit:
31 1tane_welly, Dr.PathRoch, mona_PHX and 28 others
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Jul 22, 2024 at 11:40 PM#2
Step 1 — Know your plan's criteria BEFORE the appointment
I called UHC and asked for the "clinical coverage determination guidelines" for tirzepatide (Zepbound). The rep emailed me a 4-page PDF. Key requirements:
- BMI ≥30 OR ≥27 with one comorbidity
- Documentation of 6 months of lifestyle modification (diet/exercise)
- One failed prior weight loss attempt
- No active eating disorder diagnosis
- Prescribed by or in consultation with endocrinology or obesity medicine
Step 2 — Build your file
I brought my doctor:
- 12 months of MyFitnessPal food logs (printed)
- Gym check-in records from Planet Fitness (6 months)
- Previous Weight Watchers membership receipt from 2024
- Lab work showing elevated fasting insulin and A1C of 5.9
- Blood pressure readings averaging 138/88
Step 3 — The appointment
I told my PCP exactly what UHC needed documented. She wrote the PA narrative hitting every single bullet point from the coverage criteria. She also listed diagnoses: obesity (E66.01), prediabetes (R73.03), hypertension (I10).
30 0BiostatsBrad, PeptideSynthNJ, Dr.KarenChen and 27 others
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Jul 23, 2024 at 12:20 AM#3
I'm genuinely jealous. I'm on my third denial with Cigna for Wegovy. Each time they come back with a different reason — first it was "insufficient documentation of lifestyle modification," then "medication not medically necessary," now "patient does not meet BMI criteria" even though my BMI is literally 36. My doctor is ready to throw her computer out the window.
29 24MariaRD, AussieAnna, BethLabQueen and 26 others
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Browse GL BiochemJul 23, 2024 at 1:00 AM#4
That BMI denial when your BMI is 36 is almost certainly a clerical error. Check if the PA submission has your correct height and weight. I've heard of cases where the height was entered in centimeters instead of inches, making the calculated BMI wrong. Also request the actual denial letter — it has to cite the specific clinical criteria you didn't meet. If it's factually wrong, you can file a rapid appeal.
28 23Dr.KarenChen, Dr.NateNeph, PharmD_Rodriguez and 25 others
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Jul 23, 2024 at 4:44 AM#5
I'm a nurse who submits PAs for a bariatric practice. Everything said is correct, and here's what I'd add:
1. Use the insurer's own PA form, not a generic one. UHC, Cigna, Aetna all have specific forms on their provider portals. Using the right form reduces back-and-forth by about 60%.
2. Attach documentation proactively. Don't wait for them to request records. Attach labs, office visit notes documenting BMI, and any specialist consultation upfront.
3. Submit early in the week. Monday-Wednesday submissions get reviewed faster because review nurses have less backlog. Friday submissions sit until Monday.
4. Electronic submission > fax. Always. Faxed PAs get lost constantly.
27 22julia.endo, JessicaM_2024, TomFromTexas and 24 others
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