We’re in the middle of a major shift in how we treat obesity, diabetes, and metabolic disease. GLP-1s have changed the game. But as usual, the people who need these medications most are being blocked—not by science, but by insurance red tape.

Coverage decisions vary wildly—and they’re changing fast. What your plan covers today might change next quarter. What was approved for a friend may be completely denied for you. Some plans require extreme BMI thresholds. Others won’t count progress if you paid out-of-pocket. And many still exclude GLP-1s entirely for weight loss, regardless of your health risks or clinical need.

Over the past several months, we’ve dug deep into this rapidly developing landscape—reviewing hundreds of real-world denials, studying shifting coverage criteria, and collaborating with patients, providers, and advocates to understand what actually works when it comes to securing insurance coverage for GLP-1s. We’ve built an appeals system that not only reflects the reality of this fight—but helps people win it.

No paperwork. No hold music. No fax machines. Just a simple, powerful way to get your appeal in motion—with the right evidence, the right strategy, and into the right hands. So you can get back to focusing on what matters: Your health.

Read on for the most common challenges with GLP-1 coverage, and what you can do if you get denied. And if you haven’t already, you can read more about why this medication matters in this letter from our CEO.

Common GLP-1 Coverage Questions (And How We Help)

• How do I qualify for a GLP-1 prescription?
• Why did my insurance stop covering my GLP-1 after it was working?
• Can I switch from a compounded GLP-1 to a brand-name one?
• What can I do if my insurer forces me to switch medications?
• My plan says GLP-1s aren't covered - can I still appeal?

Getting Coverage for a New GLP-1 Prescription

The challenge: Insurers often require you to meet extreme and unreasonable criteria, which can feel like an impossible bar to clear. 

Whether you’re starting Wegovy, Zepbound, or Mounjaro, getting your first prescription covered can feel like hitting a moving target. That’s because more than half of all plans with GLP-1 coverage apply criteria that are more restrictive than FDA guidelines— and criteria are changing every few months.

Some plans require BMIs as high as 40 (when the FDA standard for eligibility is 30) or multiple co-morbidities like cardiovascular disease, hypertension and obstructive sleep apnea. Others demand months of participation in a costly weight management program before considering medications. Many limit approval to just a few months, with no guarantee of continuation. And some plans require you to fail on ineffective treatments before they’ll cover what actually works—which could put your health at risk.

How we fight it:

A clear, evidence-backed appeal, personalized to your unique health story and insurance policy, is key to getting coverage. When you appeal through Claimable, we  show:

• How you meet the standard criteria: BMI, A1c, co-morbidities, lifestyle changes.
• Why restrictive requirements—like excessive documentation or arbitrary program rules—don’t reflect medical necessity, clinical standards or applicable laws.
• Why step therapy or “preferred” drugs aren’t safer or better for you.

A denial doesn’t mean you don’t qualify. It means the insurer wants you to give up. With the right appeal, we’re here to make sure you don’t.

Continuing Coverage When You're Making Progress

The challenge: Once you see success on a GLP-1, insurers can use it as justification to stop covering you.  

When a GLP-1 is working, you know it: weight is coming down, blood sugar is steady, and related conditions—like high blood pressure or sleep apnea—are improving. But instead of that progress ensuring continued access, insurers often use it as a reason to demand new paperwork—or worse, to cut you off.

FDA guidance allows up to a year to demonstrate a 5% weight loss. But some plans push for three times that weight loss in one-third the time—setting unrealistic, and potentially unsafe, targets that deny care despite clear clinical benefit. Insurers claim your progress means you no longer need treatment. And if your GLP-1 journey hasn’t been a straight line, your coverage could disappear altogether.

That’s where we come in.

How we fight it:

We’re here to make sure your progress counts—and keeps counting. Claimable’s continuation appeals includes four key arguments to keep you on track. 

• Highlight your progress—weight loss, A1C improvement, better sleep, lower blood pressure, and other real clinical gains.
• Clarify gaps and changes—like switching from compounded meds, adjusting your dose, or managing prior authorization delays.
• Hold insurers accountable—to medical guidelines, continuity of care protections, and coverage terms that support ongoing treatment.
• Ensure your plan follows fair, consistent policies—challenging short approval windows, moving goalposts, and arbitrary rules that ignore your rights.

If your medication is working, you shouldn’t have to fight harder just to keep going.

Switching from Compounded To Brand-Name

The challenge: As of May 22, 2025, compounded copycat GLP-1s are off the market. Getting covered for the branded version of your exact same meds? Not so easy.

While branded GLP-1s were in shortage, many compounding pharmacies offered lower-cost alternatives that proved to be very popular, with an estimated 2-4 million Americans prescribed a compounded GLP-1. Now that the FDA-declared shortage has ended, those pharmacies are no longer permitted to produce copies of brand-name drugs like Wegovy or Zepbound.

Compounding pharmacies can still prescribe and produce custom formulations when medically necessary, but these medications come with risks. They don’t go through the same rigorous safety and efficacy testing as FDA-approved drugs, which means they could increase health risks or be less effective.

Now, many patients are being told they don’t qualify for coverage of a branded GLP-1 — even if they would have qualified initially and the compounded version was working well.

Common barriers include:

• You’ve already lost weight and no longer meet the starting BMI requirement.
• Your insurer won’t count your cash-pay or compounded treatment history.
• You’re using a GLP-1 to manage conditions like sleep apnea or cardiovascular disease — and insurers are ignoring the full picture.

How we fight it:

We build personalized appeals to make your case — showing medical necessity, continuity of care, and the real-world value of staying on treatment. Your right to access a compounded medication during the shortage was protected. Your full medication history should count now, too.

You shouldn’t have to start over — or pay $400 to $700 out of pocket — just because the rules changed.

Fighting Forced Switches

The challenge: You know what works. Your insurer wants to change it.

More and more patients are being forced to switch GLP-1 medications—not because of medical need, but because insurers want to cut costs or capture rebates. These non-medical or formulary switches happen when a payer—not your provider—chooses your medication based on their bottom line.

For example: CVS Caremark recently dropped Zepbound from its formulary, pushing millions of patients to switch to Wegovy starting July 1.

These switches often have nothing to do with your health, and sometimes they don’t even lower your costs. Instead, they can disrupt care, increase side effects, and lead to worse outcomes.

GLP-1 medications in particular are sensitive to disruption. Patients and providers often spend months carefully titrating to the right dose. Restarting with a new medication can trigger setbacks, new side effects, and reduced effectiveness. And medications like Zepbound and Wegovy aren’t interchangeable—they have different mechanisms of action, indications, and side effect profiles.

If your current GLP-1 is working and well-tolerated, there may be no clinical reason to change. That decision should stay between you and your provider—not your insurer.

How we fight it:

Claimable helps you push back with a personalized appeal—built to preserve the treatment that’s working for you (and your wallet). Our forced-switch appeals:

• Make a continuation of care case, showing how switching could harm your progress,especially with medications that require careful titration.
• Highlight clinical differences between your current and proposed medication to demonstrate they aren’t interchangeable.
• Surface real-world evidence of your stability, symptom improvements, and the risks of disruption.
• Challenge the lack of medical justification for switching patients who are stable and responding well.
• Frame fiduciary risks under ERISA for the majority of employer-based plans that are self-funded.
• Flag legal and ethical concerns, particularly in states with protections against non-medical switching.

How to Appeal Plan Exclusions or “Not Covered”

The challenge: More and more plans are excluding GLP-1s from coverage.

If your denial says weight loss medications are “not a covered benefit,” you’re likely dealing with a plan exclusion—one of the hardest types of denials to fight. These exclusions are written directly into your insurance contract, often banning coverage for weight loss medications across the board—or blocking specific drugs like Zepbound or Wegovy—regardless of medical need.

The tough truth? About half of all health plans exclude GLP-1s for weight loss.

The silver lining? Most people with obesity also have another condition that GLP-1s are approved to treat—like type 2 diabetes, cardiovascular disease, or sleep apnea. And new FDA indications are being added all the time.

How we fight it:

Even if your plan excludes weight loss treatment, there are still ways to push back:

• Resubmit with a different diagnosis, if one applies.
• Request a formulary exception, especially if no equivalent alternative exists.
• Ask for a continuation of care exception, especially if you were previously covered—many states require it.
• Ask your employer to change or override the policy if you’re on a self-funded plan. 
  Tip: Most large employers self-fund their plans, which means leadership—not the insurer—has the final say and a fiduciary duty to act.
• File a complaint or consult a lawyer if your plan was misleading during enrollment.
  Tip: Misrepresentation, breach of contract, or unfair practices may violate consumer protection laws

These appeals are harder to win—but not impossible. And the policy landscape is shifting fast. Lawsuits, new guidance, and growing public pressure are forcing insurers to reconsider blanket exclusions.

The Bottom Line

GLP-1 medications are transforming lives—but too often, access depends on your paperwork, not your progress or potential.

Insurers are hoping the red tape wears you down. That you won’t appeal. That you’ll switch, stop, or give up.

At Claimable, we’re here to make sure you don’t.

Whether you’ve been denied, dropped, or told you’re not covered, we’ll help you fight back—with expert strategies, AI-powered tools, and appeals tailored to your unique medical story and your plan’s real rules.

Because you deserve access to the treatment that’s working.

Because your health shouldn’t hinge on fine print.

Because one denial shouldn’t be the end of your story.

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We get asked all the time for tips on how to write an effective Letter of Medical Necessity (LOMN). It’s one of the most critical tools in challenging an insurance denial, yet many providers aren’t sure what makes a letter truly persuasive.

After reviewing hundreds—some that succeeded, others that failed—we started to see clear patterns in what works and what doesn’t. A well-crafted LOMN isn’t just about paperwork; it’s a powerful tool to make insurers recognize what providers already know: the treatments you prescribe aren’t optional, they’re necessary.

That’s why we put together this guide: to help providers make that case clearly, confidently, and successfully.

What is a Letter of Medical Necessity?

A LOMN is a formal document from the treating provider explaining why a treatment, medication, or service is medically necessary. It can serve as a provider appeal on its own or support a prior authorization request or patient appeal.

Why the Letter of Medical Necessity Matters

A LOMN can be the deciding factor in whether a patient gets the care they need. 

When making coverage decisions, insurers often rely on reviewers with limited or no expertise in the condition, a history of concerning decisions, and no insight into the patient’s history—yet they make life-changing decisions in minutes. Investigations have shown that providers and patients who appeal more frequently face fewer denials over time. By challenging every unjust denial, you fight for your patient’s care today and help prevent future denials.

An effective LOMN establishes your authority as the treating provider, documents the patient’s relevant medical history, and presents clear clinical justification for why the treatment is essential—dramatically improving the chances of approval.

Let’s break down exactly what makes a LOMN effective—and how to write one that insurers can’t ignore.

How to Write a LOMN That Gets Results

When a prior authorization or appeal is needed, act quickly. A clear, structured LOMN can make all the difference. Here’s how to do it:

1. Review the Criteria: Examine the insurer’s coverage criteria or the specific denial  reasons to identify what must be addressed in the letter.
   
2. Initiate the Process: Inform your patient that a LOMN will be part of the appeal and discuss any additional details that could strengthen or expedite the case.
   
3. Gather Key Information:  Gather medical records, clinical studies, and relevant guidelines to build a strong, evidence-backed argument.

Essential Components of an Effective LOMN

To ensure your LOMN is impactful, include these key sections:

• Introduction: Briefly state your credentials and role in the patient’s care to establish expertise. Highlight your direct involvement in diagnosis, treatment planning, and ongoing management.

• Diagnosis: Clearly state the diagnosis, how it affects daily functioning, and why specific codes matter. If applicable, note progression or complications that make timely treatment essential. Specify how the patient meets standard clinical criteria.
• Medical History: Summarize past treatments, including durations, outcomes, and why they were ineffective. If any treatments were discontinued, specify the reasons (e.g., side effects, lack of efficacy). Address needed exceptions to step therapy.
  
• Necessity of Treatment: Explain why this is the most appropriate (or only) option, considering medical necessity, patient-specific factors, and cost-saving benefits for patients and insurers/employers. (See example: CSRO Letter on White Bagging) 
  
• Non-Standard Criteria: Call out insurer policies that use non-standard criteria that contradict clinical guidelines. For example, denying the only FDA-approved treatment for patients with rheumatoid arthritis or cancer.
  
• Supporting Evidence: Include relevant medical records, lab results, and imaging. Reference clinical guidelines and peer-reviewed studies to strengthen your case and ensure the latest research is on record for future appeals and legal action.
  
• Urgency: Highlight risks of delaying treatment, particularly if deterioration or irreversible harm is likely. If relevant, include studies showing long-term consequences of delayed care.

Did you know? You can request a 72-hour expedited appeal if a delay risks your patient’s health. Your LOMN must state the urgency and document at least one risk factor, such as hospitalization, severe pain, ongoing care, disability risk, or time-sensitive treatment. Some states, like Illinois, broadly define urgency, including impairments to maximal function.

Final Thoughts

An effective LOMN not only strengthens your patient’s appeal but reinforces your role as the expert on their care. It’s a powerful tool that forces insurers to recognize the real-world impact of their decisions. By laying out the necessity of treatment in clear, compelling terms, you make it harder for them to justify a denial. And by challenging every unjust denial, you help create accountability—making insurers less likely to deny necessary care in the future.

At Claimable, we believe everyone should get the care and coverage they deserve. That’s why we’ve built tools to help providers challenge denials faster and more effectively. If you’re ready to take control of the appeals process, join us.

Ready to empower your practice and transform how you handle appeals?

Sign-up now for more expert resources and join our community of forward-thinking providers.

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Watch the Interview with PANDAS Network's Executive Director, Diana Pohlman, and Claimable's CEO, Warris Bokhari sharing how to fight IVIG denials with Claimable.

Webinar Hosted by PANDAS Network:

Helping Families Appeal IVIG Insurance Denials: A Conversation with PANDAS Network

Health insurance denials for IVIG therapy can be a major hurdle for families affected by PANDAS/PANS. That’s why we were honored to join a recent webinar hosted by Diana Pohlman, Executive Director of PANDAS Network, where our CEO and Co-Founder, Warris Bokhari, MD shared how Claimable is helping families navigate the appeals process.

I didn’t appreciate…how unique what you’re doing is in our modern era right now. Utilizing AI not for the distance future, but for the here and now.
—Diana Pohlman, Executive Director, PANDAS Network

During the conversation focuses on the challenges families face when seeking IVIG coverage and how Claimable’s AI-powered tools are making a difference in successfully overturning denials.

Check out the Webinar at PANDAS Network.

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When insurers deny you the care and coverage you deserve, it’s time to stand up, know your rights, and challenge violations head-on. This beginner's guide to patient appeals will cover ten essential patient rights everyone should know.

Imagine this.

You’ve been denied health insurance coverage for a treatment your doctor says you desperately need. That’s the reality more patients are facing as insurers increasingly rely on artificial intelligence and auto-denials, often without proper review. Mistakes are skyrocketing, and insurers aren’t always following the rules.

But here's the silver lining: you have the power to push back.

The Affordable Care Act (ACA) grants patients strong appeal rights that go beyond the protections health providers can request on their behalf.

Beyond well known protections for pre-existing conditions, coverage limits and preventative health services, the ACA also protects Americans from unjust denials. These rights are further supported by similar laws in the Employee Retirement Income Security Act (ERISA), Health and Human Services (HHS) and in all 50 states.

When insurers deny you the care and coverage you deserve, it’s time to know your rights and challenge them head-on. Every Claimable appeal is tailored to do just that, which is why patients using Claimable are successful 85% of the time—1.7 times higher than the industry average.

Not sure what your rights are?

Start Here: 10 Essential Appeal Rights to Fight Health Insurance Denials

1. Right to Multiple Appeals

You are entitled to multiple levels of patient appeals, including internal appeals, independent external reviews, judicial review and regulatory complaints. By contrast, providers are only allowed internal appeals or payment disputes.

The takeaway:

Insurance companies mess up or don't follow the rules—a lot. That's why appeals exist! Think your denial is bogus? File a patient appeal with a supporting statement from your doctor. And if your first attempt doesn't cut it, keep escalating for more chances to win.

Read the fine print:

What appeal options must an insurer provide?

"Each health insurance issuer shall provide an internal claims appeal process and shall comply with the applicable external review process." (ACA, 42 U.S.C. § 300gg-19(a)-(b); ACA, 45 CFR § 147.136)

What types of appeals can request an external review?

You can request an external review after completing all internal appeals if you disagree with your insurer's decisions on issues involving medical judgement, like:

• Medical necessity of care
• Appropriateness of care
• Health care setting
• Level of care
• Effectiveness of a covered benefit
• Experimental and investigational treatments

2. Right to a Qualified (Human) Reviewer

Your appeal must be reviewed by a healthcare professional—not an algorithm—with the right clinical expertise in treating your condition. And no, they're not supposed to be incentivized to deny your claim.

The takeaway:

Always ask for the National Provider Identifier (NPI) to confirm your reviewer’s qualifications. And if there’s evidence the insurer retaliates against fair reviewers or rewards those who deny claims, that could be a powerful argument for your case.

Read the fine print:

Who can review and decide your appeal?

"Such reviewer shall be a person with appropriate expertise who was not involved in the initial determination."  (ACA, 42 U.S.C. § 300gg-19(b)(2))

What conflicts of interest must reviewers avoid?

"[T]he plan and issuer must ensure that all claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision. Accordingly, decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) must not be made based upon the likelihood that the individual will support the denial of benefits." (ACA, 45 CFR § 147.136 (b) (2) (ii) (D))

3. Right to a Full and Fair Review

Insurance companies must conduct a comprehensive review of all the information submitted with an appeal. This includes giving you the opportunity to present new evidence and ensures your access to your claim file.

The takeaway:

Use this to your advantage! If you've got new evidence that supports you case, use it. And don't forget to ask for your case file—it can contain valuable insights that back your case and you're entitled to see everything they used to make their decision.

Read the fine print:

What types of information must reviewers take into account?

“Provide for a review that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.”
(ERISA, 29 CFR § 2560.503-1(h)(2)(iv); ACA, 42 U.S.C. § 300gg-19(a)(2)(A))

What information must a reviewer share with you?

"[A]llow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process."  (ACA, 42 U.S.C. § 300gg-19(a)(1)(C))

Learn more: How to Request and Review Your Claim File.

4. Right to Clear and Timely Notification

Insurers must give a written explanation for any denial, with appeal instructions, within these timeframes: 72 hours for urgent needs or formulary exceptions,15 days for prior authorizations, and 30 days for standard reviews.

The takeaway:

Demand your denial notice in writing—it’s your roadmap for fighting back. If they stall, report them to your regulator. The notice, often called a Notice of Adverse Benefit Determination or Explanation of Benefits (EOB), reveals why you were denied and outlines your appeal rights.

Read the fine print:

What must a denial notification include?

"The notification shall be set forth, in a manner calculated to be understood by the claimant—(i) The specific reason or reasons for the adverse determination; (ii) Reference to the specific plan provisions on which the determination is based; (iii) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material of information is necessary; (iv) A description of the plan's review procedures and the time limits applicable to such procedures..."
(ACA, 42 U.S.C. § 300gg-19(a)(4); 29 C.F.R. § 2560.503-1(g))

Do I need to be able to understand it?

"Provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes."
(ACA, 42 U.S.C. § 300gg-19(a)(1)(B))

How long does my insurer have to notify me of my appeal decision?

"Your insurer must notify you in writing and explain why:
Within 72 hours for urgent care cases
Within 15 days if you’re seeking prior authorization for a treatment
Within 30 days for medical services already received"
(healthcare.gov; 29 C.F.R. § 2560.503-1(f)(2))

How long for formulary exception request decisions?

"A health plan must make its determination on a standard exception and notify the enrollee or the enrollee's designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 72 hours following receipt of the request." (C) (1) (ii)
45 C.F.R. § 156.122 (c) (1) (ii)

How long do external reviews take?

"Standard external reviews are decided as soon as possible – no later than 45 days after the request was received. Expedited external reviews are decided as soon as possible – no later than 72 hours, or less, depending on the medical urgency of the case, after the request was received."
(29 C.F.R. § 2560.503-1(f)(2))

5. Right to Formulary and Tier Exceptions

You can request and gain access to clinically appropriate medications not otherwise covered by your plan. If approved, the plan must cover the full prescription duration, waive dosing restrictions, or lower costs.

The takeaway:

Is your medication "not covered"? Ask for a formulary exception! It's fast and if they deny it, you can escalate. If the medication is necessary and alternatives won’t work or could harm you, this lets you request full coverage, override limits, or get non-preferred drugs at preferred prices. Tip: doctor's statement is sometimes required.

Read the fine print:

Can I appeal if my medication is 'not covered by the plan'?

"A health plan must have a process for an enrollee, the enrollee's designee, or the enrollee's prescribing physician (or other prescriber) to request a standard review of a decision that a drug is not covered by the plan."
45 C.F.R. § 156.122 (c)

When can I ask for an urgent (24-hour review) of my formulary exception?

"Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug."
(45 C.F.R. § 156.122 (c))

How long do granted exceptions last?

"A health plan that grants a standard exception request must provide coverage of the non-formulary drug for the duration of the prescription, including refills... A health plan that grants an exception based on exigent circumstances must provide coverage of the non-formulary drug for the duration of the exigency."
(45 C.F.R. § 156.122 (c))

Can I also request exceptions to formulary tiers?

For Medicare: "A tiering exception should be requested to obtain a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier."
(CMS, Medicare Exception Policy)

6. Right to Adequate Network

Insurance companies must provide access to a sufficient number of providers within a reasonable distance and time frame, guaranteeing patients timely access to necessary medical care without excessive travel or delays​. (NCSL)

The takeaway:

Don’t settle for long waits or drives—your plan must provide timely, nearby care that meets your needs. If the network falls short or if switching providers would cause a risky gap in care, you may qualify for in-network coverage elsewhere.

Read the fine print:

How do I know if my network is adequate?

"Health plans must maintain a network that is sufficient in number and types of providers to ensure that all services are accessible without unreasonable delay." (45 CFR § 156.230)

How does my state decide if my network is adequate?

Find your state's law, here: National Conference of State Legislatures.

7. Right to Safe & Suitable Site of Care

Patients have the right to receive care in a setting that is safe, effective, and appropriate for their medical needs. This includes protection from being forced into unsafe, discriminatory, or inaccessible sites of care.

The takeaway:

Your care, your choice! Plans shouldn’t force you away from your trusted team or push you to facilities with higher costs, longer commutes or unsafe care. Fight to stay with the providers who truly understand your needs—it's worth it.

Read the fine print:

"The patient has the right to receive care in a safe setting."
(ACA, 42 C.F.R. § 482.13(c))

8. Right to Safe Step Therapy

In 38 states, laws protect patients from being forced into potentially harmful or ineffective treatments through ‘fail-first’ step therapy protocols. These protections allow patients to request exceptions to step therapy rules when the patient is stable on their current treatment or the health plan’s preferred drug is unsafe.

The takeaway:

Take control of your treatment! Step therapy protections empower you to request exceptions if a preferred drug isn’t right or if you're stable on your current care. Know your rights—fight back to stay on the care that keeps you healthy.

Read the fine print:

What is an example is a state's step therapy law?

Example state language: "A health insurer shall expeditiously grant a request for a step therapy exception...if a prescribing provider submits necessary justification and supporting clinical documentation supporting the provider’s determination that the required prescription drug is inconsistent with good professional practice..." (California AB-347)  (S.652 - Safe Step Act)

What makes a health plan's preferred drug unsafe?

Under most states laws, and a proposed federal law, exceptions must be granted when any of the following apply to a health plan's preferred drug therapy is:

• Contraindicated or likely to cause adverse reactions
• Expected to be ineffective based on the patient’s medical history
• Previously tried and proven ineffective
• Expected to worsen an existing co-morbid condition
• Likely to reduce the patient’s ability to perform daily activities
• A barrier to adhering to the patient’s current therapy or care plan

What restricts forced switching when on stable treatment?

Many states require exceptions for patients who are stable on their current treatment, preventing insurers from enforcing non-medical switching to alternative medications by restricting coverage or raising out-of-pocket costs.

What protects Medicare Advantage members?

As of the 2024 plan year, the Centers for Medicare & Medicaid Services (CMS) prohibits Medicare Advantage plans from enforcing coverage criteria, including step therapy, that is stricter than traditional Medicare. (CMS)

9. Right to Evidence-Based Decisions

Insurers must determine the medical necessity of your treatment based on credible scientific evidence and standards accepted by the medical community. These decisions should never be arbitrary or purely cost-driven.

The takeaway:

If your insurer tries to override your doctor’s orders or ignore accepted standards, push back. Request your Summary Plan Description (SPD) to confirm if they’re following their own rules and challenge any outdated or unsubstantiated policy.

The fine print:

What is the standard for determining which treatments should be covered?

"Base clinical decisions on the strength of scientific evidence and standards of practice, including assessing peer-reviewed medical literature, pharmacoeconomic studies, outcomes research data, and other such information as it determines appropriate." (ACA, 45 CFR § 156.122(a)(3)(iii)(B))

Who decides what care is medically necessary for you?

"A doctor’s attestation that a service is medically necessary is an important consideration. Your doctor or other provider may be asked to provide a “Letter of Medical Necessity” to your health plan as part of a “certification” or “utilization review” process." (NAIC, What is Medical Necessity?)

Where can you find a definition for medical necessity?

"Definitions for medical necessity include a requirement that the treatment is within the accepted standards in the medical community.  This is defined in the health plan’s medical policy. A health plan must make its medical policy available to you if it is used to make a decision to deny you coverage." (NAIC, What is Medical Necessity?)

10. Right to Have All Copays Count

Patients are entitled to have all payments—including those made through third party assistance programs—count toward their deductibles and out-of-pocket maximums.

The takeaway:

Although a federal court struck down copay accumulator programs in September 2023 for treatments without generic equivalents, some insurers still try to enforce them, betting that patients won’t know their rights or push back.

The fine print:

What should be excluded from accumulators or maximizers?

From NCSL: “Insurers are now precluded by federal regulation from implementing co-pay accumulators for drugs that lack generic equivalents.” (NCSL; All Copays Count; HIV and Hepatitis Policy Institute et al v. HHS)

You can find specific language about your health insurance appeal rights within the ACA, from HHS and from the Department of Labor (ERISA).

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After success reversing Cigna denial for Idaho family, Claimable expands appeals platform to help all children obtain essential care.

PANS/PANDAS families can now get free appeal support, starting soon.

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SACRAMENTO, Calif., Nov. 21, 2024 (GLOBE NEWSWIRE) (updated Nov. 25, 2025)

Claimable, a pioneering healthcare technology company, today announced the launch of its free AI-powered appeals platform designed to help children with PANS/PANDAS overcome insurance denials and access critical intravenous immunoglobulin (IVIG) treatment.

Families can start a free appeal now by visiting www.getclaimable.com/pans-pandas.

The Claimable platform leverages purpose-built AI to analyze clinical research, policy details, appeals data, and patients’ unique medical stories, generating and submitting customized insurance denial appeals in minutes.

The PANS/PANDAS solution was inspired by the family of Gianna Coulter. After being denied IVIG treatment three times by their insurer, Cigna, Gianna lost the ability to speak, eat, and walk for the majority of the day. Claimable stepped up to support them in filling a customized appeal. Within 96 hours they won. Cigna’s decision was reversed and they were reimbursed for previously made out-of-pocket payments. On the heels of this success, Claimable is now offering appeals support to all PANS/PANDAS patients at no cost, ensuring families do not incur any additional expenses in their fight for care.

"When I spoke to the Coulter family, it was clear to me that not only was this a medical issue of their daughter desperately needing care, but also the economic hardships would be more than any family could reasonably bear,” shares Warris Bokhari, co-founder and CEO of Claimable.

“I spoke to 12 families across 12 different states in the span of two days, and their stories were heartbreaking; divorces, foreclosures, bankruptcy - all to get access to one treatment and give their kids a shot. There was no way we could sit this out."

1 in 200 children in the US are estimated to be affected with PANS/PANDAS, a brain disorder that causes sudden onset psychiatric symptoms. The widely recommended treatment for PANS/PANDAS is IVIG, which involves infusing a patient with a concentrated pool of antibodies from healthy donors. IVIG is the mandated treatment in 12 states, but throughout the rest of the country families are facing senseless denials, and children are suffering and denied critical care.

“For far too long, families affected by PANS/PANDAS have faced senseless barriers when seeking insurance coverage for IVIG treatment, leaving them to navigate complex appeals processes alone while their children suffer needlessly. This free resource will empower thousands of families to advocate for the care their children desperately need. It would have been a huge support to my family, as well,” said Diana Pohlman, Advocate & Executive Director, PANDAS Network.org.

On average, a single IVIG infusion costs over $9,000 out of pocket, with some children requiring multiple infusions over years. Claimable has the potential to save families hundreds of thousands of dollars in out-of-pocket expenses. At a time when 100 million Americans struggle with medical debt, insurance coverage has never been more critical. Research shows that without adequate coverage, 60% of people delay care, and 47% experience worsening health as a direct result.

In addition to PANS/PANDAS, Claimable supports affordable appeals for over 70 life-changing treatments, focusing on commonly denied medications for autoimmune and migraine sufferers. The company aims to rapidly increase its impact, expanding to over 100 treatments by early 2025. This growth will include support for patients with Multiple Sclerosis, Cardiac Diseases, Diabetes, Obesity, Asthma, and individuals battling certain cancers. Claimable submits appeals via Fax and First Class Mail, requesting urgent 72-hour reviews when appropriate. Each appeal costs $39.95, plus shipping, except PANS/PANDAS appeals which are being offered for free.

Claimable is available nationwide and accepts denials from all insurance providers, including Medicare, Medicaid, United Healthcare, Anthem, Aetna, Cigna, and BCBS plans.

For more information about Claimable’s PANS/PANDAS tool, visit www.getclaimable.com/pans-pandas.

To learn more about Claimable and all of the treatments they support, visit www.getclaimable.com.

About Claimable: Claimable is revolutionizing the way patients fight healthcare denials, helping ensure everyone has access to the care they need and the coverage they deserve. The platform leverages custom-built AI to analyze clinical research, policy details, appeals data, and patients’ unique medical stories, generating and submitting customized appeals in minutes. Claimable is available nationwide, accepting denials from all insurance providers, including Medicare and Medicaid. As an NVIDIA Inception Program member, Claimable continues to push the boundaries of AI innovation in healthcare. For more information visit www.getclaimable.com.

Contact: Emily Fox, press@getclaimable.com

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Pilot Program Boasts Industry-Leading Results with 80% Success in Under 10 Days

Sacramento, CA - October 2, 2024

Claimable, a pioneering healthcare technology company, today announced the launch of its AI-powered appeals platform designed to combat unjust healthcare denials. The platform leverages purpose-built AI to analyze clinical research, policy details, appeals data, and patients’ unique medical stories, generating and submitting customized appeals in minutes. 

"At Claimable, we're harnessing the power of AI to give patients a voice in a system that too often drowns them out," said Warris Bokhari, MD, CEO and Co-Founder of Claimable. "Our mission is to level the playing field, ensuring every patient can reclaim control over their healthcare and get the treatment they’re owed."

The results from Claimable’s pilot program far exceed industry standards:

• An 80% appeal success rate (1.6x more than average)
• Most cases resolved in under 10 days (3x faster than average)
• Appeals submitted in minutes–not days
• Nearly $3M recovered for patients

These data illustrate the platform's potential to significantly impact millions of lives and protect patient rights amidst a broken insurance system. Annually, 850 million of the 5 billion U.S. health claims are denied, leading to care delays for 60% of affected patients, and 47% reporting worsened health as a result. Furthermore, 100 million Americans are in medical debt, accounting for 66% of personal bankruptcies. Claimable is addressing this mounting national healthcare crisis by empowering patients to swiftly challenge unjust denials, helping them access vital treatments, reduce financial burdens, and prevent critical care delays.

"Claimable’s AI-driven approach is a game changer for patients who have been unfairly denied care," said Julie Baak, Practice Manager at Arthritis Center in Bridgeton, Missouri. "It gives them a fighting chance to overturn these decisions and get the right coverage for the right treatment."

Currently, Claimable supports appeals for 60 life-changing treatments, focusing on commonly denied medications for autoimmune and migraine sufferers—conditions affecting nearly 65 million Americans, of which 80-85% are women. The company aims to rapidly increase its impact, expanding to over 100 treatments by early 2025. This growth will include support for patients with Multiple Sclerosis, Cardiac Diseases, Diabetes, Obesity, Asthma, and individuals battling certain cancers. 

"The healthcare system in this country is fundamentally broken, with millions of patients denied the care they need due to profit-driven practices," said Wendell Potter, Claimable advisor, health insurance reform expert and former insurance executive. "Claimable offers a critical remedy. This platform is a lifeline for those caught in the machinery of an industry that too often prioritizes dollars over lives."

The platform’s guided appeal builder offers smart document scanning, a dynamic health questionnaire, and instant evidence matching. Unlike static form-based tools, Claimable delivers a personalized experience that adapts to responses in real time. Each appeal generated features a compelling, fact-based narrative, tailored to the patient’s unique circumstances and story. 

Claimable is now available nationwide and accepts denials from all insurance providers, including Medicare, Medicaid, United Healthcare, Anthem, Aetna, Cigna, and BCBS plans. Claimable submits appeals via Fax and First Class Mail, requesting urgent 72-hour reviews when appropriate. With affordability at its core, Claimable charges a fee of $39.95 per appeal, plus shipping.

For more information about Claimable or to join the waitlist for future conditions, visit www.getclaimable.com. 

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About Claimable:

Claimable is revolutionizing the way patients fight healthcare denials, helping ensure everyone has access to the care they need and the coverage they deserve. The platform leverages custom-built AI to analyze clinical research, policy details, appeals data, and patients’ unique medical stories, generating and submitting customized appeals in minutes. Claimable is available nationwide, accepting denials from all insurance providers, including Medicare and Medicaid. As an NVIDIA Inception Program member, Claimable continues to push the boundaries of AI innovation in healthcare. For more information visit https://www.getclaimable.com/.

Contact:

Emily Fox

press@getclaimable.com

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