After working in healthcare for ten years, Robert Romano thought he knew how health insurance worked—until he needed medication for his sleep apnea, and found himself without coverage.
Sleep apnea is a disorder where a person’s breathing repeatedly starts and stops during sleep. The most common type of sleep apnea is obstructive sleep apnea, where someone’s throat muscles relax and block the flow of air into the lungs.
The condition can increase people’s likelihood of developing heart disorders, Type 2 diabetes, and strokes—all of which run in Romano’s family.
“You really need to manage it aggressively,” Romano, who is a licensed clinical social worker and psychotherapist, said. “I have a cardiologist, I had an endocrinologist, and I take my meds and all that.”
In the past few years, Romano experimented with a variety of traditional sleep apnea treatments, but nothing worked for him. At the end of last year, Romano’s doctor recommended he try Zepbound.
Zepbound is usually prescribed as a weight-loss drug, but it has been found to have more versatile applications. In December 2024, Food and Drug Administration (FDA) officials approved Zepbound to treat sleep apnea. Currently, it is the only FDA-approved drug that treats this condition.
“My doctor had, at that point, exhausted all remedies for obstructive sleep apnea,” Romano said.
Prior to taking Zepbound, Romano says he was also on Ozempic for a few months, for weight loss, but he stopped taking it at the end of 2024.
“My endocrinologist… essentially said, ‘Hey, you know, there’s this drug that was approved by the FDA at the end of last year that’s approved for sleep apnea, plus it’s a GLP-1 like Ozempic, and this might do the trick for you.’ So he prescribed it back in February,” Romano said.
The drug worked, but there was a problem: Romano’s health insurance plan with Anthem Blue Cross and Blue Shield explicitly denies coverage for weight-loss drugs. It didn’t matter that Romano needed Zepbound for sleep apnea; Anthem wouldn’t approve his prescription.
Romano, who is self-employed, is insured through AccessHealth CT, Connecticut’s state-run insurance marketplace. He said he looked at private insurance plans, but they were not financially viable for him. Anthem, like every insurance company, has a list of medical conditions it will treat and drugs it will cover in every policy. Sometimes, insurance companies will offer coverage for certain drugs, even if they treat conditions that are not covered by a plan. Under Romano’s policy, Ozempic is covered with a high copay, but Zepbound is not.
Through reviewing Romano’s medical records, state statutes, and correspondence between the state officials, Anthem, and Romano, Inside Investigator found that insurance companies can deny coverage for “medically necessary” drugs and treatments if there is an exclusion clause in an insurance contract. When this happens, state officials have limited authority to force companies to change their decisions.
For the last eight months, Romano, his doctor, and Connecticut Assistant Attorney General Thomas Ryan have been trying to get Anthem to cover Zepbound for Romano’s sleep apnea, but Anthem officials have refused to reverse their decision. And in the meantime, he has been paying $500 a month out of pocket to get the medication he needs.
Things may change soon. This legislative session, the General Assembly modified “An Act Concerning Health Insurance and Patient Protection.” The amended act now has new provisions that limit when and how health insurance companies can deny coverage to patients.
“Even when Medically Necessary”
For months, Anthem has explicitly acknowledged that Romano may need Zepbound to treat his sleep apnea, but refused to cover the cost of the medication, citing their blanket ban on covering weight loss drugs for people with his insurance plan.
Weight loss drugs, and GLP-1s in particular, are expensive. Many studies suggest they improve certain health outcomes for individuals in the long term, but they do not reduce the net cost of health care for many providers. To top it all off, one in eight adults has used a GLP-1 drug already, and more than 135 million people in the country could be eligible to use the drug for weight loss benefits alone.
Anthem is not unique in its denial. Insurance companies across the country are restricting coverage of weight loss drugs. Last year, less than one-fifth of large private companies offered weight loss drugs in their insurance plans—down from one in four companies in 2023—and Medicare and Medicaid plans do not cover anti-obesity drugs prescribed for the sole purpose of weight loss either.
In Connecticut, state employees are offered Anthem insurance plans. People on those plans can only get approval for anti-obesity medication if their physicians are a part of a Connecticut Children’s Weight Management program, or Flyte Health, which is a virtual weight loss program for adults.
In the fiscal year 2024, Connecticut spent $103 million to cover GLP-1 medications through Medicaid and for state employee insurance plans. By the end of this fiscal year, the state anticipates it will spend $150 million to cover GLP-1 drugs through Medicaid and another $60 million through state employee insurance plans. To cut back on costs, the Department of Social Services (DSS) is looking at ways to manufacture GLP-1 drugs in the state.
Connecticut recently modified its Medicaid program to expand the coverage of certain weight loss drugs for severely obese adults. However, none of these drugs are GLP-1s, which is the class of drugs that Ozempic and Zepbound fall into. This expanded coverage began on June 1, and DSS officials estimate that it will increase annual aggregate expenditures by around $500,000 by the end of this fiscal year. In fiscal year 2026, it is estimated that this expanded coverage will increase the annual aggregate expenditures by more than $4 million.
There are workarounds to the ban on weight loss drugs in Romano’s plan, but Anthem has refused to entertain them in his case.
When Anthem denied Romano’s Zepbound coverage in February, he immediately submitted an appeal. Then, on Feb. 28, Romano received a letter from Anthem denying that appeal.
The letter, which was sent from one of Anthem’s Grievances and Appeals analysts, stated, “In reviewing this matter, I evaluated all aspects of the request and based on the information we have, I cannot change the previous coverage decision. The basis of this decision is that the medication Zepbound is non-covered and does not appear on the Anthem prescription drug list. Also, your health plan does not provide coverage for weight loss medication. This denial does not represent a determination of medical necessity. The denial is based solely on your benefits.”
Romano’s doctor filed for an expedited appeal on April 1.
In that letter, his doctor wrote, “Zepbound represents a clinically proven, FDA-approved treatment option that addresses both conditions (moderate to severe obstructive sleep apnea and obesity) simultaneously and has demonstrated significant efficacy in improving (obstructive sleep apnea) severity and symptoms. As stated in the plan’s “Health Plan Individual Case Management” section, Anthem pays “provide benefits for alternate care that is not listed as a Covered Service” and “extend Covered Services beyond the Benefit Maximums of this Plan” when doing so would be “in the best interest of You and Anthem.” Given the medical necessity of this treatment and the patient’s exhaustion of covered alternatives, I believe this case warrants such consideration.”
Federal law requires insurance companies to respond to appeals within 30 days if the disputed medical service has not been provided, 60 days if it has been provided, and 72 hours if there is an expedited appeal.
Anthem didn’t acknowledge this request until April 3, when company representatives asked Romano to give his doctor permission to discuss his medical records with them, according to a letter written by his endocrinologist that was shared with Inside Investigator.
On April 11, Anthem sent a receipt of acknowledgement and then said they would respond to Romano’s appeal within 20 days, which means that they should have responded to him by May 1 at the latest. However, by May 30, neither Romano nor his doctor had heard back from Anthem about this appeal, so his endocrinologist reached out again. He re-sent all of the documents he had previously submitted and requested a peer-to-peer review, which is the process of a health care provider and an insurance company discussing the medical necessity of a treatment.
On June 9, Anthem finally concluded the internal review and upheld the initial decision. Anthem representatives never followed up with the doctor’s request for a peer-to-peer review.
Since Romano could no longer make direct appeals to the insurance company, he turned to the Connecticut Insurance Department (CID) for help. That, too, didn’t go the way he hoped.
“One obstruction after another”
The CID is a state government agency with a mission to “offer guidance, support, and education and regulate the industry in a way that promotes fair competition and makes sure insurance is available to everyone.” To that end, the agency has a process to help people whose insurance claims have been denied.
Every year, the department gets around 6,000 complaints. These complaints include issues with every type of insurance contract—health, home, auto, etc., according to CID’s Director of Consumer Affairs, Gerard O’Sullivan. He estimates that around 10-15% involve actual violations, while most of the complaints are about “gray areas” in contracts.
If someone unsuccessfully appeals a decision from their health insurance company, they can petition the state for an external review through the CID External Review Program.
According to the CID’s 2025 Managed Care Report, the state received 739 requests for external reviews in 2024, but only 381 were accepted for review. Another 328 were deemed “ineligible” for a review, and 30 were withdrawn before a review could happen.
There is a process people have to follow to get an external review. First, they need to try to sort the problem out directly through their health insurance company. That requires them to appeal a decision and, if that is rejected, request an internal review. Once the insurance company’s internal review is complete and the patient has received written notification of this process, they have 120 days to submit a request for an External Review.
When they submit this request, they need to send a letter of support from a treating physician, treatment notes, and, in the case of experimental treatments, relevant medical literature to justify the physician’s recommended treatment. If someone needs urgent care, which may be necessary if delaying treatment puts someone’s life at risk or jeopardizes their chances of making a full recovery, they can get a waiver to skip having to appeal decisions through their insurance companies.
After all of that, an independent review organization (IRO) that is contracted by the CID will review the claim. A standard review should take 45 days to complete. At the end of the process, the IRO can uphold the insurance company’s decision, reverse it, or revise it. IROs overturn almost 40% of all cases it reviews, according to the CID.
External reviews only cover cases where a treatment is rejected because it is deemed medically unnecessary. IROs do not look at issues with contracts.
Romano submitted his request for an external review on July 16—76 days after Anthem should have completed its internal review, and 37 days after he received a letter formally completing the review.
His request for an external review was denied on July 21.
An IRO led by Insurance Associate Examiner Christopher Banach rejected Romano’s request for an external review on procedural grounds.
The letter that was shared with Romano said, “The denial of health care services is not eligible for review under the external review program. External Review is only available for denials based on the health carrier’s determination that the services do not meet the requirements for medical necessity, appropriateness, health care setting, level of care, effectiveness of the health care service, experimental and/or investigational, eligibility to participate in the health carrier’s health benefit plan, rescission of coverage or request for in-network exceptions.”
However, Romano spoke to Banach over the phone and claims that Banach said he missed the 120-day window to apply for a review. That would only be true if the 120-day window started before he applied for an internal review from Anthem. Romano sees this as evidence that his full record was not reviewed.
“I did, quote-unquote, everything the ‘right way,’ and it’s just been on obstruction after another, and being gaslit,” Romano said.
While on the phone with Banach, he also mentioned how the IRO did not take into consideration what Romano called Anthem’s “procedural failures,” which include taking too long to complete the internal review, rejecting his request for an expedited review, and refusing to schedule a peer-to-peer meeting with his doctor.
In the end, Romano says Banach committed to filing a complaint against Anthem for how the company handled his appeal process, but would not force them to overturn their appeal.
Banach could not be reached for questions about this decision or the conversation he had with Romano.
A few weeks before Romano requested an external review, he filed a complaint against Anthem with the state. He alleged that the company broke its own policies when it did not provide him with an expedited appeal back in April.
In a letter to the State Insurance Inspector Robert Fisher, Anthem representatives reiterated that the decision not to cover Zepbound and to reject his request for an expedited appeal was based on policy, not Romano’s medical needs.
“Excluded items will not be covered even if the service, supply or equipment is Medically Necessary,” a risk analyst from Anthem wrote in a document sent to a state insurance examiner. “Zepbound is primarily used for weight loss. The denial of Zepbound is due to the contractual exclusion and not based on medical necessity.”
The letter went on to explain that Anthem representatives reviewed the study Romano sent them, which substantiated the benefits of Zepbound to treat sleep apnea. In order for Romano to get approval for Zepbound, he would need to submit multiple additional tests.
In a letter he sent to his endocrinologist on May 30, Romano stated that he had not received any requests for additional documentation about his condition or sleep studies. Medical records show that Romano went to an appointment at the Stamford Health Medical Group Sleep Center and was told that he did not need a “repeat sleep study, given my clinical history and current presentation. So, the repeat study is not an evidence-based requirement.”
Ultimately, state officials sided with Anthem in his complaint as well.
“We have reviewed the actions taken by your insurance carrier and find that the carrier acted in accordance with the terms of the plan,” Richard Fisher, the insurance examiner who looked at the case, wrote. “Although you may disagree with this determination, we do not show that the actions of the insurer violated state law or were inconsistent with the plan of benefits as outlined in the certification of coverage.”
At a loss, Romano reached out to the Attorney General’s office and the Office of the Healthcare Advocate. He sent them a packet that contained his insurance records, a summary of events, emails, and other documentation.
“I’m just asking for due process,” Romano said. “I’m asking… them to follow the law.”
On July 28, Assistant AG Thomas Ryan responded to Romano and said that he asked O’Sullivan to review his case and his claims that Anthem insurance did not follow their protocols, or properly consider his sleep apnea when making a decision about covering Zepbound.
“I’m a huge advocate for my patients,” Romano told Inside Investigator in an interview. “I’ve sent people to the Office of the Health Care Advocate, and to the Insurance Commissioner, and I give patient resources, I follow up, I help them through medical trauma. I trusted the system, and then this happened to me.”
As this was happening, Romano was struggling to keep up with the financial costs of his medication.
Eli Lilly, the company that manufactures Zepbound, has a discount plan for self-paying customers. Depending on the dose, a vial of Zepbound—which is injected once a week—costs between $100 and $137. On top of that, users need to pay for delivery pens or syringes to administer the drugs to themselves.
Inside Investigator saw receipts that show that, for months, Romano was paying $504 a month for Zepbound.
In order to keep this promotional pricing, Romano needs to buy his medication within certain time frames, regardless of the amount that he needs at a given time.
“It just got me in a place where I had to either pay this 500 bucks, or if I missed that deadline, I have to pay almost double,” Romano said. “All these actors that could have stepped in, in the state, and certainly Anthem, to kind of remedy this and just give me that due process. They never stepped up for me.”
Ryan did not respond to questions about Romano’s case.
Shifting the burden of proof
Romano says he has not heard back from any state official since August.
However, Elizabeth Benton, the communications director for the Office of the Attorney General, wrote in an email, “The Office of the Attorney General asked the Connecticut Insurance Department to conduct an additional review. CID conducted that review and found that the coverage exclusion was appropriately applied.”
Any complaint is reviewed at multiple levels in the CID, including the legal and consumer health departments, according to Sullivan.
Sullivan did not comment on Romano’s case.
In early October, Romano sent another email to Anthem asking them to reconsider his appeal. On Oct. 7, Anthem’s Director of Public Relations in Connecticut, Stephanie DuBois, responded to this email, stating, “We understand how important this matter is to you. However, our position remains the same, as this determination is based on benefit coverage rather than a clinical decision.”
Starting on December 5, Romano plans to stop accepting Anthem insurance plans from his patients.
“I think they (Anthem) are dishonest and I do not trust them and will not work with them,” Romano wrote in an email. “In addition, I am seeking licensure in another state other than Connecticut, and, we already have a shortage of psychotherapists, but I don’t want to be licensed by what I consider to be an immoral and corrupt system and state.”
DuBois did not answer specific questions about the process of appealing decisions and how often decisions are changed. In an email, she said, “We carefully reviewed Mr. Romano’s coverage request; however, weight loss drugs fall under an exclusion in his plan, which means it is not a covered treatment.”
“The system leaves people behind,” Romano said. “If these folks, the insurance companies, can get away without reimbursing patients and providers and whatever, they’re going to do it.”
Currently, if a health insurance company denies someone coverage, it is the responsibility of the patient to prove that they need that care. This legislative session, state legislators approved Public Act 25-94, which modified “An Act Concerning Health Insurance and Patient Protection” so that health insurance companies are required to provide a reasoning for denying someone health care treatments and, if the state’s Insurance Commissioner determines that the reasoning “does not comply with the requirements of law or if it contains a provision or provisions that are unfair or deceptive or that encourage misrepresentation of the policy,” they can override the decision.
However, this public act would not fully reform the existing external review systems in the state that Romano has been fighting with for months now. The amendment will not change how the Insurance Commissioner can penalize health insurance companies for noncompliance with these laws for conditions other than mental health disorders, stage IV cancer, multiple sclerosis, or rheumatoid arthritis. It also will not force them to expand their coverage beyond what is already required by state and federal law.
When asked about the existing enforcement mechanisms that external review boards have, Benton wrote, “The carrier is statutorily obligated to accept the decision. We aren’t aware of instances where that has not happened.”
Still, Romano is hopeful that the changes to the Public Act will help other people going forward.
“If an insurance company denies something, the burden is on them to come back to the doctor and the patient and say, ‘Hey, we’re not going to cover this because of a, b, and c,’” Romano said. “And right now, the system… is designed so your doctor and you, as the patient, has to jump through hoops to try to get medications approved.”
Some of the amendments in the act that are about treatment for mental health conditions, cancers, and certain autoimmune disorders were implemented on October 1. Most of the other amendments, including the ones that require health insurance companies to provide reasoning for denying care or coverage, will take effect on January 1, 2026.
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