Migraine Rx denials in California external review
In the California DMHC record, independent physician reviewers decided 172 published external-review cases involving Migraine Rxand overturned the plan’s denial in 83.1%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Migraine Rx denials
| Category | Decisions | Overturned |
|---|---|---|
| Migraine | 154 | 82.5% |
| Epilepsy Seizures Migraine SD | 9 | 100% |
| Headache | 4 | 75% |
What the insurer actually argued
| 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% |
What the reviewers wrote
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
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 external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Migraine Rx, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY