Letter of Medical Necessity for a GLP-1 (Free Template)

the short answer

A letter of medical necessity is the document that most often turns a denial into an approval. It states who you are, your diagnosis, your BMI, your related conditions, what you have tried, and why this medication is appropriate. Here is a template you can adapt with your clinician.

what a strong letter includes

• Your name, date of birth, and member ID
• Your diagnosis and the matching codes
• Your BMI now, and your BMI when therapy started
• Related conditions such as high blood pressure, prediabetes, or sleep apnea
• Treatments you have already tried and how they went
• A clear clinical rationale for this medication
• The exact drug and dose requested

the template

letter of medical necessity, template

To Whom It May Concern,

I am writing on behalf of my patient, \[Patient Name\], date of birth \[DOB\], member ID \[ID\], to request coverage of \[Medication and dose\].

\[Patient Name\] has a diagnosis of \[diagnosis and code\], with a current BMI of \[BMI\] and a BMI of \[BMI at start\] at the start of therapy. They also have the following related conditions: \[conditions, for example high blood pressure, prediabetes, sleep apnea\].

We have previously tried \[prior treatments and outcomes\], which were \[ineffective or not tolerated\]. In my clinical judgment, \[Medication\] is medically necessary because \[rationale tied to the patient\].

I respectfully request approval of \[Medication and dose\]. Please contact me with any questions.

Sincerely, \[Clinician name, credentials, NPI, contact\]

tips that make it land

• Be specific to you. Generic letters get generic denials.
• Name the related conditions. They often matter more than weight alone.
• Attach records that let the plan verify each claim.
• Match the drug and dose to what was prescribed.

a specific, well-documented letter is the single best tool in an appeal.

where it goes

Your clinician submits the letter with your prior authorization or appeal. Keep a copy for your records, and ask for the plan's decision in writing.

questions people ask

What is a letter of medical necessity?

A document from your clinician explaining why a medication is medically necessary for you, used to support coverage or an appeal.

Who writes it?

Your clinician writes and signs it, but you can prepare the details and a draft to make it easier.

Does a template guarantee approval?

No, but a complete, specific letter overturns a large share of denials, especially when paired with the right documentation.

What should I attach?

Records of your BMI, your diagnoses, and any past treatments you tried, so the plan can verify the case.

See if you qualify and get started

This article is for education and is not medical advice. Coverage rules change often and vary by plan, state, and diagnosis; confirm current details with your plan or at cms.gov before acting. Reviewed by Dr. Linda Moleon, MD. If a GLP-1 might be right for you, talk with a licensed clinician.