Can you appeal a weight-loss drug exclusion?

The ERISA claims regulation defines an adverse benefit determination to include "A denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit", including for group health plans one "resulting from the application of any utilization review".

29 CFR §2560.503-1(m)(4), Electronic Code of Federal Regulations · source

ERISA: "The administrator shall, upon written request of any participant or beneficiary, furnish a copy of the latest updated summary ... plan description, and the latest annual report, any terminal report, the bargaining agreement, trust agreement, contract, or other instruments under which the plan is established or operated. The administrator may make a reasonable charge to cover the cost of furnishing such complete copies."

29 U.S.C. §1024(b)(4), Legal Information Institute text · source

A summary plan description must include "a statement clearly identifying circumstances which may result in disqualification, ineligibility, or denial, loss, forfeiture, suspension, offset, reduction, or recovery" of benefits. Where an insurer is responsible for financing or administering a group health plan, the SPD "shall indicate the name and address of the issuer, whether and to what extent benefits under the plan are guaranteed under a contract or policy of insurance issued by the issuer, and the nature of any administrative services (e.g., payment of claims) provided by the issuer."

29 CFR §2520.102-3(l) and (q), Electronic Code of Federal Regulations · source

The federal external review process covers "An adverse benefit determination (including a final internal adverse benefit determination) by a plan or issuer that involves medical judgment (including, but not limited to, those based on the plan's or issuer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit; its determination that a treatment is experimental or investigational ... ), as determined by the external reviewer." It excludes a denial "based on a determination that a participant, beneficiary, or enrollee fails to meet the requirements for eligibility under the terms of a group health plan or health insurance coverage".

45 CFR §147.136(d)(1)(i)(A), Electronic Code of Federal Regulations · source

HealthCare.gov lists the types of denials that can go to external review: "Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan"; "Any denial that involves a determination that a treatment is experimental or investigational"; and cancellation of coverage for false or incomplete application information. It tells readers to "Check the information on your Explanation of Benefits (EOB) or on the final denial of the internal appeal by your health plan." The notice gives the contact information for the organization that will handle your external review.

HealthCare.gov (Centers for Medicare & Medicaid Services), External review · source

Aetna states when its own criteria stop applying. Its weight reduction policy notes that "Many Aetna benefit plans specifically exclude coverage of weight reduction medications under the pharmacy benefit and/or under the health benefits plan," and continues: "The medical necessity criteria set forth below do not apply to health plans that specifically exclude services and supplies for or related to treatment of obesity or for diet or weight control. Under these plans, claims for weight loss drugs will be denied based on this exclusion." The policy's history records a last review of 03/10/2026.

Aetna, Medical Clinical Policy Bulletin 0039, "Weight Reduction Programs and Devices", effective February 2000 · source

UnitedHealthcare describes its weight-loss coverage as something an employer buys rather than something its members have. The program's own background section opens: "This is an optional program that is put in place for clients or businesses that have elected to cover weight loss products with Prior Authorization/Notification."

UnitedHealthcare, Clinical Pharmacy Programs, "Prior Authorization/Notification – Plans with Weight Loss/Appetite Suppression Medication Coverage" (2026 P 1114-22), effective September 2026 · source

A separate program exists for plans that did not buy it, and it says why: "Medications for the purpose of weight loss are typically a benefit exclusion. The program allows for coverage of Wegovy injection or tablet for the cardiovascular risk reduction indication and Wegovy injection for MASH." It will not approve Wegovy for weight loss, because that is the thing those plans exclude.

UnitedHealthcare, Clinical Pharmacy Programs, "Prior Authorization/Non-Formulary – Wegovy (semaglutide) injection, Wegovy (semaglutide) tablets – Cardiovascular Risk Reduction and MASH Only" (2026 P 1445-4), effective May 2026 · source

ERISA's penalty clause: an administrator who fails or refuses to comply with a request for information it must furnish, "by mailing the material requested to the last known address of the requesting participant or beneficiary within 30 days after such request", may at a court's discretion be "personally liable to such participant or beneficiary in the amount of up to $100 a day from the date of such failure or refusal".

29 U.S.C. §1132(c)(1), Legal Information Institute text · source

For a commercial or employer plan the window is a minimum, not a fixed number. The plan must "Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination." We read the whole section looking for a provision allowing a claimant to file late for good cause, illness or hardship, and there is none.

29 CFR §2560.503-1(h)(3)(i), Electronic Code of Federal Regulations, effective August 2026 · source

On appeal your file is yours, free. The plan must "Provide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits." Relevant is defined widely: it includes anything that "Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon," and any plan "statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant's diagnosis."

29 CFR §2560.503-1(h)(2)(iii) and (m)(8), Electronic Code of Federal Regulations, effective August 2026 · source

Where the plan used an internal criterion, you can have it for nothing. The notice must give either the rule itself or "a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request." Where the denial rests on medical necessity or an experimental exclusion, the notice must give "an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant's medical circumstances," or a statement that it will be provided free of charge on request.

29 CFR §2560.503-1(g)(1)(v), Electronic Code of Federal Regulations, effective August 2026 · source

The notice has to point at the plan language it relied on, which is how you tell a gate from an exclusion. It must contain "Reference to the specific plan provisions on which the determination is based," and "A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary."

29 CFR §2560.503-1(g)(1)(ii) and (g)(1)(iii), Electronic Code of Federal Regulations, effective August 2026 · source

Insured coverage follows a qualifying state process. The rule says that where a state external review process "includes at a minimum the consumer protections in the NAIC Uniform Model Act, then the issuer must comply with the applicable State external review process and is not required to comply with the Federal external review process of paragraph (d) of this section."

45 CFR §147.136(c)(1)(i), Electronic Code of Federal Regulations, effective August 2026 · source

A self-funded plan is not automatically in the federal process, and the text is careful about it. It covers a self-insured plan that is "subject to a State external review process that applies to and is binding on the plan (for example, is not preempted by ERISA)," and then adds: "Where a self-insured plan is not subject to an applicable State external review process, but the State has chosen to expand access to its process for plans that are not subject to the applicable State laws, the plan may choose to comply with either the applicable State external review process or the Federal external review process." Where neither route applies, "the plan or issuer must comply with the Federal external review process of paragraph (d) of this section."

45 CFR §147.136(c)(1)(ii) and (c)(1)(iii), Electronic Code of Federal Regulations, effective August 2026 · source

The consumer version of the filing window, in the government's plain-language wording: "You must file a written request for an external review within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied." ⚠ This page prints no publication or revision date of its own; August 2026 is the month we read it.

HealthCare.gov · source