Answer
The short answer
It means your file missed a specific written criterion, not that your doctor was wrong. The plan has to explain the clinical judgment it applied to you, or send that explanation free on request. Get the criterion first.
Compared to a document. Insurers publish coverage policies setting out what has to be shown for a given drug, and a medical necessity denial is nearly always a finding that the paperwork did not meet one line in one of them.
That is a much smaller problem than the phrase sounds like, and it is a different problem from the one people usually try to solve. Arguing that you need the medicine answers a question nobody asked. Finding out which criterion was not met, and whether it actually was not met, answers the one that was.
Where a denial rests on medical necessity or an experimental-treatment exclusion, the notice has to give you either an explanation of the scientific or clinical judgment for the determination applying the terms of the plan to your medical circumstances, or a statement that this explanation will be provided free of charge on request.
Note the wording. Not the plan's general policy. The judgment applied to your circumstances. A letter that recites a policy and stops has given you the first half of a sentence.
Yes. Where an internal rule, guideline, protocol or similar criterion was relied on, the notice must either contain it or say that a copy will be provided free of charge on request. On appeal the right widens: you get reasonable access to and copies of all documents, records and other information relevant to your claim, free.
Relevant is defined generously, and the definition is the useful part. It reaches anything submitted, considered or generated while the decision was being made, whether or not it was relied on, and it reaches the plan's statements of policy about the denied treatment for your diagnosis. That is the criteria document, by name.
Not the person who denied it. The review must not afford deference to the initial determination and must be conducted by a plan fiduciary who is neither the individual who made the original decision nor that person's subordinate.
And where the appeal turns on medical judgment — including whether something is experimental, investigational, or not medically necessary or appropriate — the decider has to consult a health care professional with appropriate training and experience in the field of medicine involved.
New evidence has to be taken into account too, without regard to whether it was submitted or considered the first time. An appeal is not a second reading of the same file unless you send nothing new.
This is where the answer stops being general. The criteria differ by insurer and by which benefit option your employer bought, and the same insurer publishes different numbers for different options.
The two facts below are read from insurers' own published coverage policies. Note what the requirements are made of: a documented lifestyle attempt with a minimum duration, a body mass index floor, and a measured weight-loss result to keep the coverage going. Those are things a chart either records or does not. Most denials at this stage are documentation problems wearing a clinical name.
Then you are in a better position than you feel, because the disagreement is now about a specific documented fact rather than about a judgment. Put the criterion and the evidence for it side by side in the appeal and ask which element the plan says is unmet.
Nothing on this page predicts how that comes out, and nothing here is medical or legal advice. What the rules give you is the criterion, the reasoning applied to you, your file, a fresh reviewer, and a clinician's involvement where medical judgment is in play. What you do with them is between you and your prescriber.
What to say on the phone
My claim for [drug name] was denied as not medically necessary on [date]. Please send me the coverage policy or clinical criterion this was decided against, and the explanation of the scientific or clinical judgment applied to my circumstances — the notice says both are available free of charge on request. Please also tell me which specific criterion my file did not meet.
Ask which element was unmet, not whether the decision was right. A named element is something a chart note can answer; a general disagreement is not.
If something here decides anything for you, read the source rather than our summary of it. These are the documents we opened, and the month we opened them.
A medical necessity denial has to come with reasoning applied to you. Where the determination "is based on a medical necessity or experimental treatment or similar exclusion or limit," the notice must contain "either 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 such explanation will be provided free of charge upon request."
29 CFR §2560.503-1(g)(1)(v)(B), Electronic Code of Federal Regulations, effective August 2026 · source · read August 2026
The criterion itself is available for nothing. Where "an internal rule, guideline, protocol, or other similar criterion was relied upon," the notice must give either the criterion or "a statement that such a rule, guideline, protocol, or other similar criterion was relied upon... and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request."
29 CFR §2560.503-1(g)(1)(v)(A), Electronic Code of Federal Regulations, effective August 2026 · source · read August 2026
On appeal, the whole relevant file is yours free of charge, and "relevant" is defined to include the plan's own policy documents. Information counts as relevant if it "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," or if it "constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether such advice or statement was relied upon."
29 CFR §2560.503-1(m)(8), Electronic Code of Federal Regulations, effective August 2026 · source · read August 2026
The appeal goes to someone new, and a clinician has to be involved. The plan must "Provide for a review that does not afford deference to the initial adverse benefit determination and that is conducted by an appropriate named fiduciary of the plan who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual," and where the appeal is "based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the appropriate named fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment."
29 CFR §2560.503-1(h)(3)(ii) and (h)(3)(iii), Electronic Code of Federal Regulations, effective August 2026 · source · read August 2026
Evidence you send on appeal has to be considered even if it is new. The review must "take[] into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination."
29 CFR §2560.503-1(h)(2)(iv), Electronic Code of Federal Regulations, effective August 2026 · source · read August 2026
Cigna's published criteria require a trial of behavioral modification and dietary restriction for at least three months, plus a baseline BMI of 30 or more, or 27 or more with a weight-related condition. Continuing coverage requires documented weight loss: at least 5% of baseline for Wegovy, Zepbound and Foundayo, and at least 4% for Saxenda.
Cigna, effective revised through April 2026 · source · read August 2026
UnitedHealthcare publishes the same BMI structure, with reauthorization requiring 5% weight loss for Wegovy and an initial six-month authorization for Zepbound. Its own document calls this an optional program that applies only where the employer elected to cover weight-loss products, which is why your colleague at another company can get a different answer.
UnitedHealthcare, effective September 2026 · source · read August 2026
Do not assume one BMI number applies to you. The same insurer publishes different floors for different employer benefit options: Cigna publishes both a 30 and a 32 threshold, and UnitedHealthcare's document contains a stricter tier at 40.
Cigna, effective April 2026 · source · read August 2026
American GLP is not a law firm, an insurer, a government office or a clinician, and nothing here is legal or medical advice. This page describes what published rules say. Your own plan documents and your own notice govern your case, and rules change — check the sources before you act.