{
 "note": "Coverage rules and FDA label facts quoted by the appeal letter generator (https://weighweekly.com/insurance-denied.html#appeal, site/appeal.js; inlined in that page). Each rule: text (shown as written), source (the primary source it was read on), last_verified (the day it was read), status verified | todo. A todo rule is never shown: the page shows its fallback (no figures) and the owner checks `todo`. Re-read 2026-10-13 (unchanged from 2026-10-12): the eCFR (titles 29, 42 and 45 current as of 2026-10-08), DailyMed SPL (Wegovy 06/2026, Zepbound 08/2026, Mounjaro 08/2026, Ozempic 06/2026), govinfo (42 U.S.C. 1395w-102, 1396r-8); HealthCare.gov, Medicare.gov and CMS.gov returned Access Denied to this machine and were read live through a reader proxy. Not legal advice.",
 "updated": "2026-10-13",
 "ui": {
  "bmi_under_27": "The labels cover adults with obesity, or with overweight and at least one weight-related condition; the trials behind them enrolled adults with a BMI of 30 or more, or 27 to under 30 with a weight-related condition, and plans' criteria are usually built on those numbers. With a BMI under 27, a medical-necessity appeal for weight management is unlikely to meet them; talk to your prescriber before sending it.",
  "bmi_27_no_condition": "With a BMI from 27 to under 30, the labels need at least one weight-related condition (such as high blood pressure, sleep apnea, abnormal blood lipids or prediabetes). If you have one, tick it so the letters mention it, and include the records.",
  "exclusion_low_odds": "A medical-necessity appeal rarely overturns a written benefit exclusion. These letters ask the plan to show the exclusion in writing and to consider an exception; ask HR about an exception or rider and price the cash routes at the same time."
 },
 "plans": {
  "employer": {
   "name": "Employer or job-based plan",
   "subject": "Request for review of an adverse benefit determination",
   "request_sentence": "I am requesting a full and fair review of this adverse benefit determination under my employer group health plan.",
   "documents_request": "Please send me, free of charge, copies of all documents, records and other information relevant to my claim, including the specific plan provision and any clinical criteria or guideline relied on, and let me review the claim file.",
   "urgent_sentence": "If waiting the standard time could seriously jeopardize my health, please treat this as an urgent (expedited) appeal; my prescriber's statement explains why.",
   "rules": [
    {
     "id": "internal_deadline",
     "status": "verified",
     "text": "Job-based plans must give you at least 180 days after you receive the denial to file the appeal.",
     "source": "https://www.ecfr.gov/current/title-29/section-2560.503-1",
     "last_verified": "2026-10-13"
    },
    {
     "id": "decision_time",
     "status": "verified",
     "text": "For a drug you have not received yet (a pre-service claim), the plan must decide a single-level appeal within 30 days of receiving it, or within 72 hours if it is urgent. If the plan has two appeal levels, each level has 15 days.",
     "source": "https://www.ecfr.gov/current/title-29/section-2560.503-1",
     "last_verified": "2026-10-13"
    },
    {
     "id": "documents",
     "status": "verified",
     "text": "You can ask the plan, free of charge, for copies of all documents, records and other information relevant to your claim, and you can review the claim file and present evidence.",
     "source": "https://www.ecfr.gov/current/title-29/section-2590.715-2719",
     "last_verified": "2026-10-13"
    },
    {
     "id": "external_review",
     "status": "verified",
     "text": "If the plan upholds the denial, you can usually ask for an external review by an independent review organization within 4 months of the final denial. A standard review is decided within 45 days; an expedited one within 72 hours. In an urgent case you can ask for the expedited external review at the same time as an expedited internal appeal.",
     "source": "https://www.ecfr.gov/current/title-45/section-147.136",
     "last_verified": "2026-10-13"
    },
    {
     "id": "external_scope",
     "status": "todo",
     "text": "Federal external review covers denials that involve medical judgment, such as medical necessity; a denial based only on a plan exclusion generally falls outside it, unless the dispute turns on medical judgment (for example, whether the drug is prescribed for sleep apnea or heart risk rather than weight loss).",
     "fallback": "Federal external review covers denials that involve medical judgment, such as medical necessity. Ask the plan, or your state's consumer assistance program, whether a denial based on a plan exclusion can go to external review.",
     "todo": "45 CFR 147.136(d)(1)(i)(A) lists the decisions external review covers (medical judgment, surprise billing, rescission) and leaves to the external reviewer whether a denial involves medical judgment. No rule text says outright that a weight-loss exclusion is ineligible; that reading is an inference. State external review programs may be broader. Confirm before the page states it.",
     "source": "https://www.ecfr.gov/current/title-45/section-147.136",
     "last_verified": "2026-10-13"
    }
   ]
  },
  "aca": {
   "name": "ACA Marketplace plan",
   "subject": "Request for internal appeal",
   "request_sentence": "I am requesting an internal appeal of this decision under my health plan.",
   "documents_request": "Please send me, free of charge, the specific plan provision and the clinical criteria used to make this decision, and let me review my claim file.",
   "urgent_sentence": "If waiting the standard time could seriously jeopardize my health, please treat this as an urgent (expedited) appeal; my prescriber's statement explains why.",
   "rules": [
    {
     "id": "internal_deadline",
     "status": "verified",
     "text": "File the internal appeal within 180 days (6 months) of receiving the denial notice.",
     "source": "https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/",
     "last_verified": "2026-10-13"
    },
    {
     "id": "decision_time",
     "status": "verified",
     "text": "For a drug you have not received yet, the plan must decide within 30 days; for one already received, within 60 days.",
     "source": "https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/",
     "last_verified": "2026-10-13"
    },
    {
     "id": "urgent_time",
     "status": "todo",
     "text": "An urgent appeal must be decided within 72 hours.",
     "fallback": "If waiting could seriously harm your health, ask for an urgent (expedited) appeal: it is decided faster, and you can ask for an external review at the same time.",
     "todo": "The federal rule (29 CFR 2560.503-1(i)(2)(i), applied to these plans by 45 CFR 147.136(b)) says 72 hours; HealthCare.gov's internal-appeals page says 'at least within 4 business days'. Decide which to show (or show both with sources). Re-checked 2026-10-13: HealthCare.gov still says 'at least within 4 business days' (written notice within 48 hours of a verbal decision).",
     "source": "https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/",
     "last_verified": "2026-10-13"
    },
    {
     "id": "documents",
     "status": "verified",
     "text": "You can review your claim file and present evidence and testimony during the appeal.",
     "source": "https://www.ecfr.gov/current/title-45/section-147.136",
     "last_verified": "2026-10-13"
    },
    {
     "id": "external_review",
     "status": "verified",
     "text": "If the plan upholds the denial, you can ask for an external review by an independent reviewer within 4 months of receiving the final denial. A standard review is decided within 45 days, an expedited one within 72 hours. In an urgent case you can file the internal appeal and the external review request at the same time.",
     "source": "https://www.healthcare.gov/appeal-insurance-company-decision/external-review/",
     "last_verified": "2026-10-13"
    },
    {
     "id": "external_scope",
     "status": "todo",
     "text": "Federal external review covers denials that involve medical judgment, such as medical necessity; a denial based only on a plan exclusion generally falls outside it.",
     "fallback": "Federal external review covers denials that involve medical judgment, such as medical necessity. Ask the plan, or your state's consumer assistance program, whether a denial based on a plan exclusion can go to external review.",
     "todo": "Same inference as employer.external_scope (45 CFR 147.136(d)(1)(i)(A)); state external review programs may be broader. Confirm before the page states it.",
     "source": "https://www.ecfr.gov/current/title-45/section-147.136",
     "last_verified": "2026-10-13"
    }
   ]
  },
  "partd": {
   "name": "Medicare Part D or Medicare Advantage drug coverage",
   "subject": "Request for redetermination of a Medicare prescription drug denial",
   "attn": "Attn: Part D Redeterminations",
   "request_sentence": "I am requesting a redetermination of this Medicare Part D coverage determination.",
   "exclusion_request": "Please tell me in writing the rule you relied on, and whether my prescription can be reviewed for a use that Part D covers.",
   "urgent_sentence": "If waiting the standard time could seriously jeopardize my health, please give this request an expedited (fast) redetermination; my prescriber's statement explains why.",
   "rules": [
    {
     "id": "internal_deadline",
     "status": "verified",
     "text": "Ask your drug plan for a redetermination within 65 days from the date on the plan's denial notice (the rule counts 60 days from receipt, and you are presumed to receive the notice 5 days after its date). A late request can be accepted for good cause.",
     "source": "https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/drug-plans",
     "last_verified": "2026-10-13"
    },
    {
     "id": "decision_time",
     "status": "verified",
     "text": "The plan decides a standard redetermination for a drug within 7 days, or within 72 hours if it is expedited. If it misses its deadline, the case goes to the independent review entity.",
     "source": "https://www.ecfr.gov/current/title-42/section-423.590",
     "last_verified": "2026-10-13"
    },
    {
     "id": "external_review",
     "status": "verified",
     "text": "If the plan upholds the denial, ask the Independent Review Entity for a reconsideration within 60 days after you receive the redetermination notice (Medicare.gov says 60 days from the date of the decision; CMS counts it as 65 days from the date on the notice, the extra 5 days being mail time). For a drug not on the plan's formulary, the prescriber must say why the formulary alternatives would not be as effective, would cause adverse effects, or both.",
     "source": "https://www.ecfr.gov/current/title-42/section-423.600",
     "last_verified": "2026-10-13"
    },
    {
     "id": "levels",
     "status": "verified",
     "text": "Medicare drug appeals have five levels: (1) redetermination by your plan, (2) reconsideration by an Independent Review Entity, (3) a decision by the Office of Medicare Hearings and Appeals (a hearing before an administrative law judge, or a review of the record), (4) review by the Medicare Appeals Council, (5) judicial review in federal district court.",
     "source": "https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/drug-plans",
     "last_verified": "2026-10-13"
    },
    {
     "id": "ma_pd",
     "status": "verified",
     "text": "A Medicare Advantage plan that includes drug coverage is a Part D sponsor under the Part D rules, so its drug denials follow these same Part D appeal steps; check your plan materials for its appeals address.",
     "source": "https://www.ecfr.gov/current/title-42/section-423.4",
     "last_verified": "2026-10-13"
    }
   ],
   "notes": [
    {
     "title": "Exceptions are decided fast",
     "status": "verified",
     "text": "A formulary or other exception request is decided within 72 hours of the plan receiving your prescriber's supporting statement, or 24 hours if expedited.",
     "source": "https://www.ecfr.gov/current/title-42/section-423.568",
     "last_verified": "2026-10-13"
    }
   ],
   "warnings": [
    {
     "status": "verified",
     "text": "Federal law excludes drugs used for weight loss from Medicare Part D, so a Part D appeal for weight management alone will not succeed. CMS says Part D can cover Wegovy to reduce the risk of major cardiovascular events and Zepbound for moderate-to-severe obstructive sleep apnea in adults with obesity, through the plan's formulary exception process if the drug is not on the formulary. For weight management alone, the Medicare GLP-1 Bridge ($50 a month for eligible people, July 1, 2026 to December 31, 2027) is a separate program with no appeals process: the prescriber can resubmit the prior authorization with corrected or new information.",
     "link": {
      "href": "/medicare-glp1-bridge.html",
      "text": "Who qualifies for the Bridge →"
     },
     "source": "https://www.cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge/information-part-d-plans",
     "last_verified": "2026-10-13"
    }
   ]
  },
  "medicaid": {
   "name": "Medicaid",
   "subject": "Appeal of a Medicaid prescription drug denial",
   "request_sentence": "I am appealing this decision. If it is not resolved in my favor, I may request a State fair hearing.",
   "exclusion_request": "Please tell me in writing the rule or state policy you relied on, and whether exceptions are available.",
   "urgent_sentence": "If waiting the standard time could seriously jeopardize my health, please decide this appeal on an expedited basis; my prescriber's statement explains why.",
   "rules": [
    {
     "id": "internal_deadline",
     "status": "verified",
     "text": "If a Medicaid managed care plan denied it, appeal to the plan within 60 days from the date on its notice. If the state Medicaid agency denied it directly, the state sets the time to request a fair hearing, up to 90 days from the date the notice was mailed.",
     "source": "https://www.ecfr.gov/current/title-42/section-438.402",
     "last_verified": "2026-10-13"
    },
    {
     "id": "decision_time",
     "status": "verified",
     "text": "A managed care plan must decide a standard appeal within 30 days, or within 72 hours if it is expedited; either can be extended by up to 14 days.",
     "source": "https://www.ecfr.gov/current/title-42/section-438.408",
     "last_verified": "2026-10-13"
    },
    {
     "id": "external_review",
     "status": "verified",
     "text": "If the plan upholds the denial, request a State fair hearing within the time your state sets: no less than 90 and no more than 120 days from the date of the plan's decision notice. If the plan misses its deadline, you can go straight to a fair hearing.",
     "source": "https://www.ecfr.gov/current/title-42/section-438.408",
     "last_verified": "2026-10-13"
    }
   ],
   "warnings": [
    {
     "status": "verified",
     "text": "Federal law lets state Medicaid programs exclude drugs used for weight loss, and coverage differs by state, so check your state first.",
     "link": {
      "href": "/#ww-router",
      "text": "Your state's Medicaid status →"
     },
     "source": "https://www.law.cornell.edu/uscode/text/42/1396r-8",
     "last_verified": "2026-10-13"
    }
   ]
  },
  "unsure": {
   "name": "Not sure",
   "subject": "Appeal of coverage denial",
   "request_sentence": "I am requesting an appeal of this decision.",
   "documents_request": "Please send me the specific plan provision and the clinical criteria used to make this decision.",
   "rules": [
    {
     "id": "internal_deadline",
     "status": "verified",
     "text": "The time to appeal depends on the plan: at least 180 days after you receive the denial on job-based and Marketplace plans, 65 days from the notice date on Medicare Part D, and 60 days on a Medicaid managed care plan. Your insurance card and the denial letter tell you which plan you have.",
     "source": "https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/",
     "last_verified": "2026-10-13"
    },
    {
     "id": "external_review",
     "status": "verified",
     "text": "If the plan upholds the denial, there is a next level outside the plan: external review by an independent reviewer on job-based and Marketplace plans, the Independent Review Entity on Medicare Part D, a State fair hearing on Medicaid.",
     "source": "https://www.healthcare.gov/appeal-insurance-company-decision/external-review/",
     "last_verified": "2026-10-13"
    }
   ]
  }
 },
 "drugs": {
  "wegovy": {
   "name": "Wegovy (semaglutide)",
   "short": "Wegovy",
   "weight_label": true,
   "dosing": "taken once weekly as an injection, or once daily as a tablet",
   "weight_label_letter": "Wegovy is FDA-approved, in combination with a reduced-calorie diet and increased physical activity, to reduce excess body weight and maintain weight reduction long term in adults with obesity, and in adults with overweight who have at least one weight-related condition.",
   "weight_label_lmn": "Wegovy is indicated, in combination with a reduced-calorie diet and increased physical activity, to reduce excess body weight and maintain weight reduction long term in adults with obesity and in adults with overweight in the presence of at least one weight-related comorbid condition (prescribing information, revised 06/2026).",
   "other": {
    "cvd": "Wegovy is FDA-approved, in combination with a reduced-calorie diet and increased physical activity, to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal heart attack or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight."
   },
   "source": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee06186f-2aa3-4990-a760-757579d8f77b",
   "last_verified": "2026-10-13"
  },
  "zepbound": {
   "name": "Zepbound (tirzepatide)",
   "short": "Zepbound",
   "weight_label": true,
   "dosing": "taken once weekly",
   "weight_label_letter": "Zepbound is FDA-approved, in combination with a reduced-calorie diet and increased physical activity, to reduce excess body weight and maintain weight reduction long term in adults with obesity, or adults with overweight who have at least one weight-related condition.",
   "weight_label_lmn": "Zepbound is indicated, in combination with a reduced-calorie diet and increased physical activity, to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition (prescribing information, revised 08/2026).",
   "other": {
    "osa": "Zepbound is FDA-approved, in combination with a reduced-calorie diet and increased physical activity, to treat moderate to severe obstructive sleep apnea in adults with obesity."
   },
   "source": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=487cd7e7-434c-4925-99fa-aa80b1cc776b",
   "last_verified": "2026-10-13"
  },
  "saxenda": {
   "name": "Saxenda (liraglutide)",
   "short": "Saxenda",
   "weight_label": true,
   "dosing": "taken once daily",
   "weight_label_letter": "Saxenda is FDA-approved, in combination with a reduced-calorie diet and increased physical activity, to reduce excess body weight and maintain weight reduction long term in adults with obesity, and in adults with overweight who have at least one weight-related condition.",
   "weight_label_lmn": "Saxenda is indicated, in combination with a reduced-calorie diet and increased physical activity, to reduce excess body weight and maintain weight reduction long term in adults with obesity and in adults with overweight in the presence of at least one weight-related comorbid condition (prescribing information, revised 02/2026).",
   "source": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3946d389-0926-4f77-a708-0acb8153b143",
   "last_verified": "2026-10-13"
  },
  "ozempic": {
   "name": "Ozempic (semaglutide)",
   "short": "Ozempic",
   "weight_label": false,
   "dosing": "taken once weekly",
   "approved_for": "for adults with type 2 diabetes (to improve blood sugar control, and to lower cardiovascular and kidney risks in people with type 2 diabetes), not for weight management",
   "on_label_alt": "Wegovy (semaglutide), which has the same active ingredient and is FDA-approved for chronic weight management,",
   "note": "Ozempic is FDA-approved for type 2 diabetes, not for weight management. Without type 2 diabetes, an appeal for Ozempic is unlikely to succeed; ask your prescriber about a prescription for Wegovy (same active ingredient, approved for weight management), which needs its own approval from the plan.",
   "source": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=adec4fd2-6858-4c99-91d4-531f5f2a2d79",
   "last_verified": "2026-10-13",
   "t2d_letter": "Ozempic is FDA-approved, in addition to diet and exercise, to improve blood sugar control in adults with type 2 diabetes."
  },
  "mounjaro": {
   "name": "Mounjaro (tirzepatide)",
   "short": "Mounjaro",
   "weight_label": false,
   "dosing": "taken once weekly",
   "approved_for": "for type 2 diabetes (to improve blood sugar control, and to lower cardiovascular risk in adults with type 2 diabetes at high risk), not for weight management",
   "on_label_alt": "Zepbound (tirzepatide), which has the same active ingredient and is FDA-approved for chronic weight management,",
   "note": "Mounjaro is FDA-approved for type 2 diabetes, not for weight management. Without type 2 diabetes, an appeal for Mounjaro is unlikely to succeed; ask your prescriber about a prescription for Zepbound (same active ingredient, approved for weight management), which needs its own approval from the plan.",
   "source": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d2d7da5d-ad07-4228-955f-cf7e355c8cc0",
   "last_verified": "2026-10-13",
   "t2d_letter": "Mounjaro is FDA-approved, in addition to diet and exercise, to improve blood sugar control in adults with type 2 diabetes."
  }
 },
 "todo": [
  "Statute text of the Part D weight-loss exclusion (SSA 1860D-2(e)(2)(A) and 1927(d)(2)(A)) was read on Cornell LII (42 U.S.C. 1395w-102, 1396r-8); ssa.gov returned Access Denied. Optional: confirm on ssa.gov or uscode.house.gov.",
  "Grandfathered job-based plans and plans not subject to the ACA (short-term plans, some church and government plans) follow different or no external review rules; the page does not separate them. Decide whether to add a line.",
  "State law adds to the federal minimums (for example state step-therapy exception laws and state external review programs). The letters make no state-specific claims; decide whether to add state rules.",
  "Medicaid: whether a state's Medicaid program covers GLP-1s for weight loss is shown from site/data/medicaid-states.json (home router), not from this file; its own verification dates apply."
 ]
}