For eight months, everything was working. A patient with a BMI of 38, pre-diabetes, high blood pressure, and sleep apnea had been on Zepbound, and the results were unambiguous: 45 pounds lost, lab values improved across the board. Then the insurer denied coverage. Over the two months it took Sejal Desai, MD to fight that denial through an appeal and a peer-to-peer review, the patient regained 25 pounds and developed diabetes. The medication was eventually approved again, confirming what the clinical record had already established. The damage, however, was done.
This is the central tension Desai describes in her practice: a system that demands proof of medical necessity even when the proof is sitting in the chart. "I should not have to spend weeks proving that a medication is medically necessary," she said, "when the patient's own clinical results have already demonstrated that it is." The appeal process did not uncover new information. It simply consumed time, and the patient bore the cost of that delay in ways that will now require more intensive management going forward.
A second case made the same point from a different angle. A patient with diabetes had been successfully taking a GLP-1 medication, with clear improvement in her A1c and weight. The insurer required the practice to prove medical necessity again. After multiple submissions, an appeal, and a peer-to-peer review, the medication was approved, essentially validating documentation that had existed from the start. Desai described it plainly as "absurd."
The administrative load these battles generate is not incidental. Desai estimates that prior authorizations consume five to ten hours of her time each week, accounting for gathering documentation, submitting records, responding to denials, completing appeals, and conducting peer-to-peer calls. That is time extracted from patient care, from program development, from the kind of individualized attention that obesity medicine, more than most specialties, actually requires. "If I had that time back," she said, "I would spend it improving our programs and giving patients more of the individualized attention they deserve."
What these cases share is not bureaucratic inconvenience. They represent a structural assumption embedded in prior authorization: that physician judgment requires external validation before it can be acted upon, and that this validation should repeat itself regardless of what the patient's own health trajectory shows. When a patient's A1c improves and her weight declines on a given medication, the clinical argument for continuing that medication has already been made. Requiring it to be made again, through a process that takes weeks, means something else is driving the decision. Desai does not say what that something is. She does not need to. The patient who came in with pre-diabetes and left with a diabetes diagnosis says it clearly enough.
