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Migraine Rx denials: what the review data shows
Independent reviewers have decided 172 published cases where an insurer denied Migraine Rx — and they overturned the insurer 83.1% of the time. A denial for Migraine Rx is a starting position, not a final answer.
Published decisions
172
2001–2026
Overturned
83.1%
143 denials reversed
Conditions behind migraine rx denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Migraine | 154 | 82.5% |
| Epilepsy Seizures Migraine SD | 9 | 100% |
| Headache | 4 | 75% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 163 | 84% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 9 | 66.7% |
Typical time to a decision
8 days
Most land between 3 and 19 days
Handled as urgent
55.2%
Expedited when a delay would cause harm
Recent direction
Rising
80.6% → 88.1% overturned, last three years
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient is a 33-year-old male who has been diagnosed with migraine headaches, which have been ongoing for several years. In a letter dated 12/9/22, the provider noted the patient has failed treatment with Ubrelvy and rizatriptan. The patient also reported no relief with sumatriptan. The patient was noted to have been treated with Nurtec samples for five months with great response. The Health Plan indicates that the requested treatment is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan has denied coverage for the requested treatment. At issue is whether Nurtec ODT 75 mg tablet (quantity of eight tablets for 30-day supply) is medically necessary for the treatment of the patient’s medical condition.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nurtec tablet disintegrating. The American Headache Society (AHS) assessment of the evidence for individual pharmacological therapies for acute migraine treatment reports that non-steroidal anti-inflammatory drugs (NSAIDs) and triptans are effective for the treatment of acute migraine attacks. Small molecule calcitonin gene-related peptide (CGRP) receptor antagonists are a newer drug class called gepants that include ubrogepant (brand name Ubrelvy) and rimegepant (brand name Nurtec ODT). The U.S. Food and Drug Administration (FDA) approves Nurtec ODT, an orally administered CGRP receptor antagonist, for the acute treatment of migraine, with or without aura, in adults.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nurtec tablet disintegrating 75 mg. Findings: The physician reviewer found that an assessment of the evidence for individual pharmacological therapies for acute migraine treatment, the American Academy of Neurology reports that non-steroidal anti-inflammatory drugs (NSAIDS) and triptans are effective for the treatment of acute migraine attacks. Small molecule calcitonin gene-related peptide (CGRP) receptor antagonists are a newer drug class called gepants. The U.S. Food and Drug Administration (FDA) approves the use of rimegepant [brand name Nurtec disintegrating tablet (ODT)], an orally administered CGRP receptor antagonist, for the acute treatment of migraine with or without aura in adults.
Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Emgality 120 mg/ml auto injector.The International Classification of Headache Disorders defines chronic migraine as “headache occurring on 15 or more days per month for more than three months, which, on at least eight days per month, has the features of migraine headache.” (Headache Classification Committee of the International Headache Society). Prophylactic treatments should be initiated in patients with chronic migraine. Evidence-based prophylactic medications for episodic migraine are often used for chronic migraine. These agents include topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and valproate.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Migraine Rxwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.