Prior Authorizations: Clear as Mud

Coverage for weight management medication is all over the map — and often has little to do with medical need. Unlike most other conditions, many employers and insurers still exclude any coverage for obesity treatment.

Patients are often surprised when I explain this during their first consultation. Even when they call their insurance company, the answer is rarely clear. The phrase they hear most? “It requires prior authorization (PA).”

What does that mean? It means that after I write a prescription, my office has to track down and complete a form created by the insurer. Each plan has its own forms, rules, and online portals — all of which change regularly. Just finding the right form and submitting it properly can be an administrative marathon.

And once it’s submitted? Denials often seem disconnected from the information we provided, and appeals feel like we’re simply begging them to reread what we already sent. Insurers can take 30 days to respond, often refusing expedited requests. Meanwhile, patients wait another month without treatment.

Weight Management: A Patchwork of Rules

Some employers provide excellent coverage for obesity pharmacotherapy, approving medication for anyone with:

• BMI (Body Mass Index) ≥ 27 with a related medical condition, or

• BMI ≥ 30, regardless of other conditions.

Unfortunately, most employers cover nothing at all. And in between, coverage can hinge on hoops like:

• Six months of supervised diet and exercise. Many patients feel demoralized by this requirement — who hasn’t tried diet and exercise, and why does it need “supervision”?

• Mandatory trial of phentermine/topiramate. Reasonable in theory, but often insurers demand six months, even though phentermine is FDA-approved only for three.

• Enrollment in an insurer-selected nutrition program. This removes patient choice — no other medical condition requires treatment with a company’s proprietary program.

• Higher BMI thresholds. Some plans require a BMI ≥ 35, despite the FDA’s criteria (BMI ≥ 27 with comorbidities, or ≥ 30). BMI alone is an imperfect measure of health risk.

(More on obesity pharmacotherapy from the Obesity Medicine Association.)

Obstructive Sleep Apnea

Wegovy is FDA-approved for adults with moderate to severe obstructive sleep apnea, defined as an AHI (Apnea-Hypopnea Index) ≥ 15 and BMI ≥ 30.

But insurers have made the criteria even stricter. Many now use RDI (Respiratory Disturbance Index) instead of AHI. This measure counts additional breathing irregularities, making it harder for patients to qualify — even if they meet the FDA definition.

On top of that, insurers often require:

• Proof of CPAP failure.

• Mandatory evaluation by a sleep specialist.

• Restricting approval to “severe” apnea only.

And many still refuse to cover it at all. Patients who meet FDA standards can be left without access simply because of shifting definitions.

Metabolic Associated Fatty Liver Disease

Wegovy is also FDA-approved for adults with MASH (Metabolic Dysfunction–Associated Steatohepatitis) with moderate to advanced fibrosis, but not cirrhosis. Kudos to the manufacturer for working to get this indication on formularies quickly.

Still, barriers remain. Patients must pay for liver elastography to see if they fit the narrow coverage window. If their disease is “not quite bad enough” or slightly more advanced, treatment may be denied — even when it makes medical sense to intervene.

One improvement: unlike with sleep apnea, there’s no BMI requirement here. That’s progress.

Cardiovascular Disease Risk Reduction

In 2024, the FDA approved Wegovy (semaglutide 2.4 mg) for reducing the risk of major adverse cardiovascular events (MACE) — including heart attack, stroke, and cardiovascular death — in adults with overweight or obesity and established cardiovascular disease.

This was a landmark decision because it recognized obesity treatment as not only about weight, but about preventing heart disease and saving lives. The approval was based on the SELECT trial, which showed a significant reduction in cardiovascular events among patients taking Wegovy compared to placebo.

Yet insurers are already narrowing the definition far beyond the FDA’s intent. Examples include:

• A patient who admits to smoking the occasional cigar being denied coverage.

• A patient with a coronary stent but no documented heart attack being denied, despite clear cardiovascular disease.

• Patients with other forms of cardiovascular disease (such as angina or heart failure) being denied, even when their cardiologist recommends treatment.

These restrictions undermine the very purpose of this approval: to intervene earlier, reduce risk, and save lives.

(More on this indication from the FDA announcement and the SELECT trial summary.)

The Bigger Picture

Each new indication brings with it new layers of requirements, new forms, and new deadlines — often requiring re-authorization every 6–12 months. This creates enormous administrative burden, delays care, and drives up costs without improving outcomes.

The clearest example is cardiovascular disease. When patients at high risk for heart attack or stroke — sometimes with stents already in place, sometimes with a cardiologist’s direct recommendation — are denied, we have to ask: who is this system really serving?

Take Back Prior Authorizations

It’s time to take back prior authorizations and return decision-making to where it belongs: between patients and their providers. If the FDA has determined a therapy reduces cardiovascular risk, insurers should not second-guess it with arbitrary exclusions.

Medical care is never one-size-fits-all. Let’s put resources where they matter most — into caring for patients, not paperwork.

About Rainier Medical

At Rainier Medical, we are experts in obesity medicine and prior authorizations. We see these challenges every day, and we help patients navigate them with skill and persistence. Our team offers personalized PA support, working directly with insurers to maximize the chance of approval — so patients can spend less time battling paperwork and more time getting healthier.

If you’ve been denied coverage or are unsure where to start, we can help.

Take Back Your Prior Authorization,

Valerie Hope-Slocum Sutherland, MD