Dr.RaviCardio said:

The mechanism that matters here is not stomach emptying, it is central.

Filing a mild objection. Mild because I might be wrong; an objection because nobody has addressed the case that does not fit. The affordability discussion here usually stops at individual tactics. At list price this class is out of reach for most of the people who would benefit, and no amount of appeal strategy changes that — it is a pricing problem wearing a paperwork costume.

One concrete data point for the thread. Worth knowing that the injection site changes very little. Abdomen, thigh and upper arm are bioequivalent for semaglutide, so a site change is not a plausible explanation for a bad week.

Dr.ObesityMed said:

The affordability discussion here usually stops at individual tactics.

Adding the part of the answer the thread has not reached. The dose-response is real but shallow at the top. Across STEP 1 and STEP 4 the gap between 1.7mg and 2.4mg is a couple of percentage points of body weight on average, and the average is carrying a wide spread — plenty of people at 1.7mg sit above the 2.4mg mean. If a dose is working and tolerable, "working" is the relevant variable, not "maximal".

Worth separating that from semaglutide, which this thread keeps folding into the same question. They behave differently and the advice does not transfer.

Following on from gary_naperville — and this may be the naive question:

Whether anyone has held at a sub-maximal dose long term and kept the result, or whether the maintenance data only exists at 2.4mg?

Closing the loop on my own question.

Follow-up — getting the denial reason in writing was the step that mattered. It named the criterion, and the criterion was a document I already had.