What Counts as Documented Prior Weight Loss Attempts?

Name: What Counts as Documented Prior Weight Loss Attempts?
Creator: Measured Editorial Team
Published: 2026-08-05

By Measured Editorial TeamPublished August 5, 2026Updated August 12, 2026

Insurance & Cost

There is no single national standard. Each plan sets its own criteria. Preauthorization is a decision by a health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. To learn your plan's exact documentation rule, request its internal criteria — a denial notice must describe them, free on request.

Key takeaways

There is no single national standard for "documented prior weight loss attempts." Each plan sets its own criteria, so the answer that matters is your plan's written policy, not a general list.
A notice of adverse benefit determination must describe the internal guidelines or criterion used in making the determination and inform the consumer that a copy of the internal requirements will be provided free of charge upon request. That is the most direct way to learn what your plan counts.
A notice of adverse benefit determination must describe any additional information needed to improve or complete the claim, so a denial letter usually names the gap in your specific file.
An enrollee must file an internal appeal within 180 days (6 months) of receiving notice that the claim was denied, and an internal appeal must be completed within 30 days if the appeal concerns a service the enrollee has not yet received.
Preauthorization is not a promise that the health insurance plan will cover the cost of the service or drug. Approval and payment are separate questions.

Payers do not share a single definition of "documented prior weight loss attempts." There is no single national standard. Each plan sets its own criteria. The rule that will be applied to your request sits in your own plan's coverage policy, and federal rules give you a route to obtain the criteria the plan used, free of charge, once it has made a determination.

Preauthorization is a decision by a health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. To learn your plan's exact documentation rule, request its internal criteria — a denial notice must describe them, free on request.

This page is deliberately narrow. We will not list "evidence types that count," because we do not have a verified source that says which ones do. What we can give you is the mechanism that produces the real answer for your plan, in writing, from the plan itself.

Why a plan asks for prior attempts at all

Preauthorization is sometimes called prior authorization, prior approval, or precertification. A health insurance plan may require preauthorization for certain services before the patient receives them, except in an emergency. Many insurance plans require a prior authorization before they will cover brand-name GLP-1s such as Ozempic, Wegovy, Mounjaro, or Zepbound.

Two structural facts are worth holding onto before you gather any paperwork.

First, a formulary is the list of prescription drugs covered by a prescription drug plan or other insurance plan offering prescription drug benefits. Whether a drug sits on your formulary at all is a separate question from whether your documentation satisfies a review.

Second, preauthorization is not a promise that the health insurance plan will cover the cost of the service or drug. An approval is not a payment guarantee, and no one — including us — can promise you an outcome.

Where your plan's actual documentation rule is written down

If you want to know what your plan counts, the most reliable path is to make the plan tell you. Federal notice rules are specific about what a denial must contain.

A notice of adverse benefit determination must provide sufficient information to identify the claim. It must state the specific reasons for the determination, including the denial code and its corresponding meaning. It must describe the plan's or issuer's standard used to deny the claim. Most usefully for this question, a notice of adverse benefit determination must describe the internal guidelines or criterion used in making the determination and inform the consumer that a copy of the internal requirements will be provided free of charge upon request.

If the denial rests on medical necessity, there is a further requirement. If an adverse benefit determination is based on a medical necessity, experimental treatment, or similar exclusion, the notice must provide either an explanation of the scientific or clinical judgment for the determination or a notice that such an explanation will be provided free of charge upon request.

And the notice must tell you what is missing. A notice of adverse benefit determination must describe any additional information needed to improve or complete the claim. That sentence is the closest thing to a personalized answer to "what counts" that exists — it is written by the reviewer, about your file.

Separately, claimants may obtain coding and other information relevant to their claim for benefits free of charge upon request under 29 CFR 2560.503-1(h)(2)(iii).

Timing matters while you assemble records. An insurer must notify the enrollee in writing of a denial within 15 days when the enrollee is seeking prior authorization for a treatment. An insurer must notify the enrollee in writing of a denial within 72 hours for urgent care cases.

If documentation is the stated denial reason

A denial on the ground that the requested service or treatment is not medically necessary can be appealed. A denial notice must inform the enrollee of the right to file an internal appeal.

An enrollee must file an internal appeal within 180 days (6 months) of receiving notice that the claim was denied. An internal appeal must be completed within 30 days if the appeal concerns a service the enrollee has not yet received — which is the situation for a prior authorization you have not filled.

You are not limited to what the plan already has. A claimant has the right to a full and fair review, including the opportunity to review and respond with written comments, documents, and records to any evidence or rationale under consideration. An enrollee filing an internal appeal should submit any additional information they want the insurer to consider, such as a letter from the doctor. Reviewers deciding an internal appeal must not have any conflicts of interest.

Keep a paper trail. An appellant should keep the Explanation of Benefits forms or letters showing what payment or services were denied, and should keep notes and dates from any phone conversations with the insurance company or doctor relating to the appeal, including the day, time, name, and title of the person spoken to and details about the conversation.

If the internal appeal fails, the decision leaves the insurer. An enrollee must file a written request for an external review within four months after the date they receive a notice or final determination from the insurer that the claim has been denied. Standard external reviews are decided as soon as possible and no later than 45 days after the request was received. The insurer is required by law to accept the external reviewer's decision. External review is free under the federal process, and the plan or issuer pays the independent review organization; only states that expressly allowed a filing fee as of November 18, 2015 may still charge one, capped at $25 per external review.

One current caveat: as of July 1, 2026, the HHS-Administered Federal External Review Process (FERP) is temporarily unavailable for enrollees who live in Alabama, Florida, Georgia, Texas, Wisconsin, or a U.S. territory other than Puerto Rico and whose plan or issuer uses that process; enrollees whose plan or issuer does not use the HHS-Administered FERP should follow the instructions in the notice from their plan or issuer.

A parallel route: the drug exceptions process

An enrollee has the right to follow their insurance company's drug exceptions process, which allows them to get a prescribed drug that is not normally covered by their health plan. To get a drug covered through the exceptions process the enrollee's doctor must confirm to the health plan, orally or in writing, that the drug is appropriate for the enrollee's medical condition. One ground supporting a drug exception request is that all other drugs covered by the plan have not been or will not be as effective as the drug being requested.

Where Measured fits

For patients with commercial insurance, Measured performs a benefits check to determine which medications may be covered under the patient's plan. Measured's insurance concierge team submits prior authorizations on the patient's behalf and keeps the patient updated on the insurance plan's determination. Measured names Aetna, Anthem, Blue Cross Blue Shield, Cigna, and UnitedHealthcare as commercial insurance plans it helps eligible patients use to obtain GLP-1 coverage when available through their benefits.

Measured states that if prior authorization is approved, the patient pays only their plan's copay when picking up the medication from the pharmacy. As of August 5, 2026, Measured states that while many patients have GLP-1 copays around $20, actual out-of-pocket cost depends on the patient's specific insurance plan and pharmacy benefits. As of August 5, 2026, Measured prices its program at $99/month for patients with GLP-1 insurance coverage, noting those patients may also have a medication copay.

What this page does not tell you

We are not going to publish a table of accepted evidence types, a required number of months, or a chart-note template we cannot source. Those figures move by plan and by year, and a confident wrong number here becomes a wasted submission for you. If you need the specific rule, the mechanism above gets it from your plan in writing.

Last reviewed

Last reviewed August 5, 2026. Prior authorization criteria vary by plan and are commonly revised each plan year. Nothing here predicts what your plan will decide. If you want your own benefits looked at rather than a general rule, ask to have your coverage checked against your actual plan.

Frequently asked questions

Does a food diary, gym receipt, or app screenshot count?+

We do not have a verified source that lists which evidence forms a plan accepts or rejects, so we will not guess. Your plan decides. A notice of adverse benefit determination must describe the internal guidelines or criterion used in making the determination and inform the consumer that a copy of the internal requirements will be provided free of charge upon request.

Do plans require 3 months or 6 months of documentation?+

There is no single national standard. Each plan sets its own criteria. We have no verified source for a specific required duration, so we do not state one here. Request your plan's written criteria rather than relying on a number from a general article.

Can my old primary care records be used?+

That depends on the plan's own rule, which we cannot state generally. The practical step is the denial letter itself: a notice of adverse benefit determination must describe any additional information needed to improve or complete the claim.

How do I find out exactly what my plan requires?+

Ask the plan in writing. A notice of adverse benefit determination must describe the internal guidelines or criterion used in making the determination and inform the consumer that a copy of the internal requirements will be provided free of charge upon request. Separately, claimants may obtain coding and other information relevant to their claim for benefits free of charge upon request under 29 CFR 2560.503-1(h)(2)(iii).

My prior authorization was denied for insufficient documentation. What now?+

A denial on the ground that the requested service or treatment is not medically necessary can be appealed. An enrollee must file an internal appeal within 180 days (6 months) of receiving notice that the claim was denied. An enrollee filing an internal appeal should submit any additional information they want the insurer to consider, such as a letter from the doctor.

What happens if the internal appeal also fails?+

An enrollee must file a written request for an external review within four months after the date they receive a notice or final determination from the insurer that the claim has been denied. Standard external reviews are decided as soon as possible and no later than 45 days after the request was received. The insurer is required by law to accept the external reviewer's decision.

If my prior authorization is approved, is the drug paid for?+

Not automatically. Preauthorization is not a promise that the health insurance plan will cover the cost of the service or drug. Measured states that if prior authorization is approved, the patient pays only their plan's copay when picking up the medication from the pharmacy.

Can someone submit the prior authorization for me?+

Measured's insurance concierge team submits prior authorizations on the patient's behalf and keeps the patient updated on the insurance plan's determination. No one can promise an approval.