Obesity Care Roadblocks: Insurers vs Clinical Guidelines

Medscape

06-05-2025

Caissa Troutman, MD, recently treated a patient in her early 50s who she planned to prescribe the anti-obesity medication Zepbound. The patient's insurance covered Zepbound but required prior authorization.
After going through the 'tedious' prior authorization process, Troutman learned the insurer would only cover Zepbound for patients with a body mass index (BMI) ≥ 40. Troutman's patient did not meet the approval criteria, despite clinical guidelines that recommend medication management for patients with a BMI of 27 who have a medical comorbidity.
'It was ludicrous,' said Troutman, an obesity medicine specialist and founder of WEIGHT reMDy, a direct care wellness practice in Camp Hill, Pennsylvania. 'It's so frustrating to spend all that time and effort trying to help patients get the care they need, only in the end, to confront these insurance-specific rules that do not follow evidence-based guidelines.'
Troutman had to forgo the Zepbound plan and prescribe another medication to help the patient.
Prior authorization required by insurers for certain treatments have long been a headache for physicians and patients. In a 2024 American Medical Association survey, 93% of physicians said prior authorization delay patients' access to necessary care. Data also show that on average, practices complete 39 prior authorization requests per physician per week, and doctors and staff spend about 13 hours per week completing the requests.
Common Reasons for Prior Auth Denials
Compounding the prior authorization problem for obesity care is the underlying confusion that exists among insurers about obesity and what it is, said Leslie Golden, MD, a family physician and obesity specialist based in Watertown, Wisconsin.
Golden said she's had patients lose insurance coverage simply because their BMI dropped below 30 due to effective treatment.
'That's like stopping insulin when a person with diabetes' A1c improves,' said Golden, founder of Weight In Gold, a clinic specializing in sustained weight health using health coaching and the latest medications. 'It reveals a fundamental misunderstanding of obesity as a chronic disease, not a temporary condition.'
For physicians, it's 'demoralizing' to spend time and energy fighting for care that should be standard, Golden said. In her practice, she has two dedicated staff members whose primary role is managing prior authorizations and appeals.
'That's not just my time away from patient care — it's a cost-driver for the entire healthcare system,' she said. 'We're diverting resources to navigate bureaucracy instead of investing in care delivery.'
At the practice of Anila Chadha, MD, a typical reason insurers give for denying a prior authorization is that the patient does not have morbid obesity, she said. But Chadha emphasizes the term 'morbid obesity' is no longer acceptable and is not used in any of the practice's documentation as obesity is now classified as class I, II, or III.
''Morbid obesity' is a very stigmatizing term,' said Chadha, a family physician and obesity medicine physician at Dignity Health in Bakersfield, California. 'It is very frustrating that we really don't want to use that term, and that is the reason [the insurer provides].'
Another common reason for medication denial is that the patient did not complete 6 months of doctor-supervised weight management in the last year, Chadha said. Such delays mean another 6 months before patients can access the medication, when in many cases, patients have tried weight management multiple times over their lifetime, she said.
Golden often sees denials for medications that have full US Food and Drug Administration (FDA) approval, she said, even when patients meet all clinical indications. Some payers require extensive documentation — years of weight loss history, repeated measurements, detailed metabolic labs — just to consider treatment, she added.
'One of the most frustrating and dangerous issues is the inconsistency,' Golden said. 'I've had prior authorizations denied because the plan required trial of a generic medication that isn't even approved to treat obesity, yet the same plan might deny another option for being off-label, all in the name of cost control.'
Meanwhile, Chadha has faced instances where insurers would only cover an obesity medication for her patients if they were able to dictate the dosage. For example, one patient's insurer approved the drug Wegovy. However, the insurer required that Chadha keep upping the patient's dosage.
'The dosage of medication should be a shared decision making between the physician and the patient,' Chadha said. 'The insurance company should not guide us.'
Catherine Varney, DO, said the most significant prior authorization issue her practice faces is denials due to claim information not being provided, despite the information clearly being included in the progress notes submitted with the original prior authorization.
The 'erroneous denials' create unnecessary stress for patients and significantly increase administrative workload, as she and staff are required to draft appeal letters that simply restate the same information already provided, said Varney, an assistant professor of family medicine at the University of Virginia and obesity medicine director for University of Virginia Health, both in Charlottesville, Virginia.
'I have tracked the time spent addressing this recurring problem, and on average, it adds approximately 110 minutes — nearly 2 hours — of additional work to my week,' Varney said.
Strategies for Prior Auth Pushback
Documentation is central to getting around prior authorizations and helping patients get approved, said Troutman.
'It comes down to writing down in detail what patients have done with regards to lifestyle modifications,' she said. 'Some [insurers] require proof of diets (like food logs) or of physical activity (like activity trackers).'
When patients first visit, make sure to discuss and record exactly what they have tried in the past as it relates to weight management, Chadha added. This could be working with a personal trainer or dietitian, or any online program they may have tried, she said.
Physicians should also document what treatments they are recommending to patients, such as diet and exercise guidance, protein intake recommendations, and what treatments have helped, Chadha said.
Be thorough, and tie everything back to comorbidities, clinical guidelines, and FDA indications, Golden said. Golden's practice has developed templates for letters of medical necessity, appeals, and peer-to-peer talking points that save time and strengthen their cases.
'It also helps to get familiar with your regional insurance plans,' Golden said. 'Build relationships with medical directors when possible, and don't be afraid to push back. It's tedious work, but advocacy at the individual case level can open doors for future patients.'
Varney said it's also vital to have staff who are educated about prior authorization processes and who understand the ins and outs of each major insurer. 'Having dedicated personnel in this role is essential, as learning the nuances of prior authorizations takes time and consistency,' she said.
Another crucial step is making note of any obesity-related conditions patients may have, such as obstructive sleep apnea. Tirzepatide, for example, is now FDA-approved for obstructive sleep apnea, she said. Wegovy is also more apt to get approved if a patient has a history of coronary artery disease, has had stents placed, or had a prior myocardial infarction, she said.
Equally important is clear communication with patients, Golden said. Let patients know what to expect: What documentation may be required, what steps their insurance or employer plan might demand, and how physicians will support them through it.
'This clarity gives patients a sense of control and hope, rather than leaving them feeling overwhelmed or defeated,' Golden said. 'When patients feel they have to 'earn' care, it reinforces the message that their disease is their fault. The strategy isn't just about navigating the system — it's also about standing with patients and helping them feel seen and supported while we do it.'