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Pre-diabetes: when insurers say no, reviewers often say yes
In 88 published external-review decisions involving pre-diabetes, independent physician reviewers overturned the insurer’s denial 68.2% of the time.
Published decisions
88
2001–2026
Overturned
68.2%
60 denials reversed
Most-fought treatments for pre-diabetes
What insurers denied — and how those fights ended.
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 80 | 68.8% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 8 | 62.5% |
Typical time to a decision
20 days
Most land between 14 and 21 days
Handled as urgent
14.8%
Expedited when a delay would cause harm
Recent direction
Falling
74.3% → 64.7% overturned, last three years
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Findings: The physician reviewer found that the patient has requested authorization and coverage for Wegovy. Obesity is a chronic disease, medication-assisted weight loss should be considered in patients at risk for future type 2 diabetes mellitus, and medication should be used when needed to achieve 10% weight loss in conjunction with lifestyle therapy. Obesity is defined as an “abnormal or excessive fat accumulation that may impair health”. Obesity is defined by BMI, weight in kilograms divided by the square of height in meters, in adults over 30 kg /m2.
Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for an Ozempic pen. Obesity is a risk factor for prediabetes and type 2 diabetes. Clinical trials testing lifestyle modification in conjunction with anti-obesity medication have demonstrated that weight loss can restore normoglycemia in those with prediabetes. Prediabetes and type 2 diabetes are associated with an increased risk of cardiovascular disease and related adverse events. In individuals with prediabetes, weight loss and prevention of diabetes are accompanied by improvements in cardiometabolic risk factors such as blood pressure, waist circumference, triglycerides, and high-density lipoprotein (HDL) cholesterol. In addition, these improvements have been shown to be maintained long-term. The U.S.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rybelsus tablet 14 mg. Prediabetes is a precursor to type 2 diabetes, a disease highly associated with microvascular and macrovascular disease. Patients with prediabetes have a higher average sugar than normal but not as high as those with diabetes. For patients with prediabetes, the American Association of Clinical Endocrinology (AACE) recommends lifestyle changes. Medications for obesity are recommended for patients with a body mass index (BMI) over 27 kg/m2 such as phentermine/topiramate ER, liraglutide, or weekly semaglutide.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ozempic. The U.S. Food and Drug Administration (FDA) approved the use of Ozempic, known generically as semaglutide, for lowering blood sugar in patients with type 2 diabetes mellitus based on the results from a clinical research program that included 8,000 patients, all with a history of type 2 diabetes mellitus, that showed a substantial decrease in hemoglobin (Hb) A1C levels when Ozempic was added to other standard therapies. Non-diabetic patients were excluded from the research trial. While the trial also showed evidence of weight loss in patients with type 2 diabetes on Ozempic, the FDA does not approve the use of Ozempic for weight loss.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for pre-diabetes was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.