Read your appeal, then sign it.

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 29 CFR § 2560.503-1^✓, 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 UnitedHealthcare’s published GLP-1 Coverage Criteria (CDI 03272025–A)^✓, 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 FDA-approved for chronic weight management in adults with an initial BMI of 30 kg/m² or greater (or 27 kg/m² with at least one weight-related comorbidity) as an adjunct to reduced-calorie diet and increased physical activity (NDA 215256, effective June 4, 2021)^✓. My BMI of 41.2 places me well within the approved indication. The 2023 American Heart Association/American College of Cardiology Guideline on Obesity and Heart Disease recommends GLP-1 receptor agonist therapy as a first-line pharmacological option for patients with BMI ≥ 40 kg/m² and cardiovascular risk factors (Circulation, 2023;148:e1–e67)^✓. 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, Texas Insurance Code § 1369.057 requires that an insurer grant a step-therapy exception when the required alternative drug is contraindicated, caused a prior adverse reaction, or is expected to be ineffective based on the covered person’s medical history (Tex. Ins. Code § 1369.057, eff. Sept. 1, 2021)^✓. 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 29 CFR § 2560.503-1 and 45 CFR § 147.136, which together set the 60-day standard for non-urgent internal appeals under the ACA^✓.

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