Using Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) to improve access to obesity pharmacotherapy: A practical guide for clinicians caring for youth with obesity across United States Medicaid programs: Abbreviated title: Using EPSDT to Improve Access to Obesity Pharmacotherapy.

BACKGROUND

Coverage of obesity pharmacotherapy for youth varies substantially across state Medicaid programs. This variability limits access to evidence-based treatment for pediatric obesity. The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is a federally mandated Medicaid provision requiring coverage of medically necessary services for individuals under age 21, even when such services are not included in standard state Medicaid benefits. Despite its broad scope, EPSDT remains underutilized due to limited awareness and operational complexity.

METHODS

We developed a clinician-facing, practice-oriented framework to operationalize EPSDT for pediatric obesity treatment. This approach integrates (1) review of federal EPSDT policy and statutory requirements, (2) synthesis of state-level variability in implementation, and (3) aggregation of real-world clinical workflows from centers that have successfully obtained EPSDT coverage for obesity pharmacotherapy. We outline step-by-step processes for identifying eligible patients, documenting medical necessity, submitting prior authorization requests, and managing appeals. Standardized tools, including sample letters of medical necessity, documentation templates, and clinic workflow algorithms, were created to support implementation across diverse clinical settings.

RESULTS

Key components include: (1) reframing obesity as a chronic disease with documented comorbid risk to establish medical necessity; (2) aligning clinical documentation with EPSDT statutory language; (3) integrating multidisciplinary team roles to streamline submission and follow-up; and (4) implementing structured appeal pathways when initial requests are denied. Case-based examples and state-specific considerations highlight variability in payer response and demonstrate that EPSDT can effectively override standard Medicaid exclusions when appropriately applied.

CONCLUSIONS

EPSDT represents a powerful but underutilized mechanism to expand equitable access to evidence-based obesity treatment for children and adolescents. A structured, clinician-driven approach can facilitate successful navigation of this benefit across diverse practice settings. Broader dissemination and adoption of standardized workflows may reduce disparities in access to obesity pharmacotherapy and support more consistent delivery of guideline-concordant care for pediatric obesity.