Glucagon-Like Peptide-1 (GLP) for Endocrine/Metabolic: 66.7% of denials overturned
In 9 California IMR decisions from 2025 to 2026, reviewers overturned 6 (66.7%). In the last five years: 66.7% of 9. 6 were medical-necessity disputes, 3 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2025 | 8 | 62.5% |
| 2026 | 1 | 100.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 4 | 75.0% | 66.7% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“The physician reviewer found that a patient has requested authorization and coverage for Zepbound. The patient has a well‑documented history of class 1 obesity, with an initial body mass index (BMI) of over 30 kg/m², along with weight‑related comorbidities including prediabetes, hyperlipidemia, and hypertension. The patient’s most recent weight measurement reflects improvement while on therapy. The record establishes that the …”
“The physician reviewer found that a patient has requested authorization and coverage for Zepbound. The U.S. Food and Drug Administration (FDA) approves the use of Zepbound (tirzepatide) injection for chronic weight management in adults with obesity, defined as a body mass index (BMI) of 30 kg/m² or greater, or who are overweight, defined as a BMI of 27 kg/m² or …”
“The physician reviewer found that a patient has requested authorization and coverage for semaglutide (Wegovy).The U.S. Food and Drug Administration (FDA) approved semaglutide (Wegovy) for adult patients with obesity defined as having a BMI of 30 kg/m2 or greater, or patients are overweight with a BMI 27 kg/m2 or greater with one weight-related condition, for chronic weight management to be …”
And one the reviewer upheld
“Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mounjaro. The U.S. Food and Drug Administration (FDA) approves using tirzepatide under the brand name Mounjaro for treating diabetes type 2. The FDA has not approved Mounjaro for the treatment of obesity or fatty liver disease. The question of how long to continue the pharmacotherapy therapy for …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Glucagon-Like Peptide-1 (GLP) denials for Endocrine/Metabolic overturned?
In 9 California IMR decisions from 2025 to 2026, reviewers overturned 6 (66.7%). In the last five years: 66.7% of 9. 6 were medical-necessity disputes, 3 experimental/investigational.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but they weigh the same things.
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.