Medical Necessity Letter Template for GLP-1 Drugs

[Doctor Letterhead]
[Doctor Name, MD/DO]
[Specialty - e.g., Endocrinology, Internal Medicine, Family Medicine]
[Practice Name]
[Address]
[Phone] | [Fax]

[Date]

[Insurance Company Name]
Medical Review Department
[Insurance Address]

RE: Medical Necessity Letter for [Ozempic/Wegovy/Mounjaro/Zepbound]
Patient: [Patient Full Name]
Date of Birth: [DOB]
Policy/ID Number: [Insurance ID]
Diagnosis: [Type 2 Diabetes Mellitus / Obesity / Both]
ICD-10 Codes: [E11.9 (Type 2 Diabetes) / E66.01 (Morbid Obesity) / E66.9 (Obesity)]

To Whom It May Concern:

I am writing to request approval for [Ozempic 0.25-2mg weekly / Wegovy 2.4mg weekly / Mounjaro 2.5-15mg weekly / Zepbound 2.5-15mg weekly] for my patient, [Patient Name]. This medication is medically necessary and clinically urgent based on the patient's current health status and treatment history.

PATIENT CLINICAL PRESENTATION

[Patient Name] is a [age]-year-old [gender] with [diagnosis - Type 2 Diabetes Mellitus / Obesity / Both] who presents with:

• Current A1C: [X.X]% (goal <7.0%)
• Current BMI: [XX.X] kg/m² ([height] inches, [weight] lbs)
• Comorbidities: [Hypertension, dyslipidemia, sleep apnea, NAFLD, cardiovascular disease, etc.]
• Duration of condition: [Diagnosed X years ago]

Current Complications: [Check all that apply and provide details]

• [ ] Diabetic neuropathy: [Symptoms - pain, numbness, burning in feet/hands]
• [ ] Diabetic retinopathy: [Vision changes, eye exam findings]
• [ ] Diabetic nephropathy: [Protein in urine, declining eGFR - current eGFR: X]
• [ ] Cardiovascular disease: [Prior MI, stroke, PAD, heart failure]
• [ ] Obesity-related conditions: [Severe sleep apnea requiring CPAP, joint disease limiting mobility]

PRIOR TREATMENT FAILURES

The patient has previously trialed the following medications with inadequate efficacy or intolerable side effects:

1. Metformin

• Trial period: [Dates or duration]
• Dosage: [Up to XXXX mg daily]
• Outcome: [Choose one:]
  • [ ] Inadequate efficacy: A1C remained [X.X]% despite therapeutic dosing
  • [ ] Intolerable side effects: Severe GI distress (nausea, diarrhea, bloating) requiring discontinuation
  • [ ] Contraindication: Chronic kidney disease (eGFR [XX]) / liver disease / lactic acidosis risk

2. [Sulfonylurea - glyburide, glipizide, glimepiride] (if applicable)

• Trial period: [Dates or duration]
• Dosage: [XX mg daily]
• Outcome: [Choose one:]
  • [ ] Inadequate efficacy: A1C remained [X.X]%
  • [ ] Intolerable side effects: Hypoglycemia episodes ([frequency]), weight gain ([XX lbs])
  • [ ] Contraindication: High hypoglycemia risk due to [occupation/age/comorbidity]

3. [Other medications trialed] (DPP-4 inhibitors, SGLT-2 inhibitors, insulin, weight loss medications)

• [List any other relevant medication trials with dates, doses, and outcomes]

CLINICAL URGENCY AND MEDICAL NECESSITY

[Drug name] is medically necessary for this patient NOW, and delaying treatment for 6-18 months while trialing additional medications poses unacceptable clinical risks including:

1. Progression of diabetic complications: [Patient's current A1C of X.X% and existing [neuropathy/retinopathy/nephropathy] indicate high risk of irreversible damage with continued suboptimal glucose control.]
2. Cardiovascular risk: [Patient has [established CVD/high CV risk factors including diabetes duration >10 years, hypertension, dyslipidemia]. GLP-1 receptor agonists have demonstrated 20% reduction in major adverse cardiovascular events in SELECT trial.]
3. Weight-related health deterioration: [Patient's BMI of XX.X with comorbidities including [sleep apnea/NAFLD/joint disease] will worsen during prolonged delay. Weight loss with GLP-1 therapy is critical to prevent irreversible organ damage.]
4. Quality of life: [Patient's [diabetes complications/obesity] significantly impair [mobility/work capacity/mental health]. Effective treatment should not be delayed by insurance administrative requirements.]

EVIDENCE-BASED SUPERIORITY OF GLP-1 THERAPY

[Drug name] is FDA-approved for [Type 2 Diabetes / Obesity] and has demonstrated superior efficacy compared to older medications:

For Ozempic/Wegovy (Semaglutide):

• SUSTAIN trials: Mean A1C reduction of 1.5-2.0% vs 0.5-1.0% with older diabetes medications
• STEP trials: Mean weight loss of 15% body weight vs 2-5% with older obesity medications
• SELECT trial: 20% reduction in major adverse cardiovascular events (MI, stroke, CV death)

For Mounjaro/Zepbound (Tirzepatide):

• SURPASS trials: Mean A1C reduction of 2.0-2.5%, superior to semaglutide
• SURMOUNT trials: Mean weight loss of 15-21% body weight
• Dual GLP-1/GIP agonism provides enhanced metabolic benefits

Given the patient's inadequate response to prior therapies and high-risk clinical profile, GLP-1 therapy represents the most appropriate next step consistent with American Diabetes Association and American Association of Clinical Endocrinology guidelines, which recommend GLP-1 receptor agonists as preferred second-line therapy (not third or fourth-line after additional step therapy failures).

PATIENT-SPECIFIC RISK FACTORS

Additional factors making GLP-1 therapy medically urgent for this patient:

• [ ] Family history: [Premature CVD, diabetic complications requiring amputation/dialysis/vision loss]
• [ ] Occupation: [Commercial driver/pilot/heavy equipment operator requiring stable blood glucose, no hypoglycemia risk]
• [ ] Pregnancy planning: [Excellent glycemic control needed pre-conception to prevent congenital anomalies]
• [ ] Mental health: [Depression, anxiety, eating disorder history - weight loss critical for mental health improvement]
• [ ] Mobility limitations: [Joint disease, spine problems - weight loss necessary to prevent disability]

CONCLUSION AND REQUEST

Based on the above clinical information, I am requesting approval for [Drug name and dosing] for [Patient Name]. The patient has exhausted appropriate prior therapies, and further delay poses serious risk of irreversible complications including [specific risks for this patient].

This medication is:

• ✓ FDA-approved for the patient's diagnosis
• ✓ Supported by high-quality clinical trial evidence
• ✓ Consistent with current treatment guidelines
• ✓ Medically necessary to prevent serious health deterioration

[For urgent appeals, add:] I am requesting EXPEDITED/URGENT review of this prior authorization request as delaying treatment poses serious jeopardy to the patient's life or health.

I am available for peer-to-peer discussion at your convenience. Please contact my office at [phone] to schedule.

Thank you for your prompt attention to this medically urgent matter.

Sincerely,

[Doctor Signature]
[Doctor Name, MD/DO]
[Board Certification - e.g., Board Certified in Endocrinology]
[State Medical License Number]
[NPI Number]

Enclosures:

• Recent lab results (A1C, lipids, kidney function)
• Pharmacy records documenting prior medication trials
• Medical records documenting complications (if applicable)
• Clinical trial citations (if submitting supporting literature)