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The typical denied patient: Female, age 38 to 52 BMI 32 to 41 Prediabetes (A1C 5.9% to 6.3%) or newly diagnosed type 2 diabetes (A1C 6.5% to 7.2%) Medicaid coverage through a state that requires A1C above 7.5% for GLP-1 approval Tried metformin for 60 to 90 days with partial response (A1C dropped from 7.0% to 6.7%, not enough to meet state threshold) Provider submitted PA, denied for "A1C not above threshold" The denial is technically correct under the state's criteria, but clinically frustrating