What is the best note wording to get Zepbound (tirzepatide) approved for an obese patient with Obstructive Sleep Apnea (OSA)?

Documentation Strategy for Zepbound (Tirzepatide) Prior Authorization in Obese Patients with OSA

Your clinical note should explicitly document that the patient has obesity (BMI ≥30 kg/m²) or overweight (BMI ≥27 kg/m²) with OSA as a weight-related comorbidity, has failed or inadequately responded to comprehensive lifestyle intervention, and requires anti-obesity pharmacotherapy per American Thoracic Society guidelines for OSA management. 1, 2

Essential Documentation Elements

Primary Diagnosis Documentation

• Document specific BMI value (must be ≥27 kg/m² with OSA, or ≥30 kg/m² without additional comorbidities) 1, 2
• State OSA diagnosis explicitly with severity classification (mild, moderate, or severe) and the apnea-hypopnea index (AHI) value from polysomnography or home sleep testing 3
• Link obesity and OSA causally: Note that "obesity is an established etiologic risk factor for this patient's obstructive sleep apnea" 1, 3

Prior Treatment Failure Documentation

• Document comprehensive lifestyle intervention trial: Specify that patient participated in a program including reduced-calorie diet, exercise/increased physical activity, and behavioral counseling for an adequate duration (typically 3-6 months minimum) 1
• Quantify inadequate response: State specific weight loss achieved (if <5% at 3 months or insufficient to improve OSA) and document persistent OSA symptoms or elevated AHI despite lifestyle modifications 1
• Note CPAP status: Document whether patient is using positive airway pressure therapy, adherence level, and whether symptoms persist despite optimal PAP therapy 3

Clinical Justification Language

Use this specific wording framework:

"Patient has obesity (BMI [X] kg/m²) with moderate-to-severe obstructive sleep apnea (AHI [X] events/hour). Despite participation in comprehensive lifestyle intervention including reduced-calorie diet, structured exercise program, and behavioral counseling for [X] months, patient achieved only [X]% weight loss, which is insufficient for meaningful OSA improvement. Per American Thoracic Society guidelines, patients with OSA and BMI ≥27 kg/m² who have inadequate response to lifestyle intervention are appropriate candidates for anti-obesity pharmacotherapy. Tirzepatide is FDA-approved for treatment of moderate-to-severe OSA in adults with obesity and has demonstrated significant reductions in AHI (mean reduction 20-24 events/hour), body weight, hypoxic burden, and improvement in sleep quality in SURMOUNT-OSA trials." 1, 2, 3

Supporting Clinical Details to Include

Cardiovascular and metabolic comorbidities (if present): Document hypertension, type 2 diabetes, dyslipidemia, or cardiovascular disease, as these strengthen the indication for weight management 1, 2

OSA-related complications: Note daytime somnolence (Epworth Sleepiness Scale score if available), sleep impairment, hypoxic burden, or elevated inflammatory markers (hsCRP) 3

Quality of life impact: Document specific functional impairments from OSA and obesity affecting daily activities, work performance, or safety (e.g., driving risk) 1

Contraindications ruled out: Explicitly state "no active cardiovascular disease" and "no contraindications to GLP-1/GIP receptor agonist therapy" 1, 2

Common Pitfalls to Avoid

• Do not simply state "patient is obese with OSA" without quantifying BMI and AHI values with specific numbers 3
• Do not omit documentation of lifestyle intervention failure - insurers require evidence that first-line therapy was attempted 1
• Do not use vague language like "patient tried diet and exercise" - specify the comprehensive nature of the intervention (diet + exercise + behavioral counseling) 1
• Do not fail to mention FDA approval - explicitly state that tirzepatide is FDA-approved for moderate-to-severe OSA in adults with obesity, which strengthens the medical necessity argument 2, 3

Additional Supporting Evidence

Reference guideline recommendations: The American Thoracic Society conditionally recommends evaluation for anti-obesity pharmacotherapy in patients with OSA and BMI ≥27 kg/m² whose weight has not improved despite comprehensive lifestyle intervention 1

Cite clinical trial data: SURMOUNT-OSA demonstrated that tirzepatide reduced AHI by 20.0-23.8 events/hour compared to placebo, with improvements evident as early as 4 weeks and statistically significant by 20 weeks 4, 3

Emphasize weight-independent benefits: Note that tirzepatide improves OSA through both weight reduction and potential weight-independent mechanisms affecting sleep-disordered breathing 4, 3

Document monitoring plan: State that you will assess weight, BMI, and OSA symptoms regularly, with follow-up sleep studies planned to evaluate AHI and oxygen saturation improvements 2