Nurtec denials in California external review
In the California DMHC record, independent physician reviewers decided 22 published external-review cases involving Nurtecand overturned the plan’s denial in 86.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Migraine | 19 | 84.2% |
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. | 19 | 84.2% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3 | 100% |
What the reviewers wrote
Where the denial was overturned
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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nurtec disintegrating tablet. Per the American Headache Society (AHS), calcitonin gene‐related peptide monoclonal (CGRP) antibodies are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebo‐controlled trials. The U.S. Food and Drug Administration (FDA) has approved Nurtec, an orally administered CGRP receptor antagonist, for the acute treatment of migraine with or without aura in adults and preventive treatment of episodic migraine in adults. The FDA approved Nurtec based on results of a randomized, double-blind, placebo-controlled trial by Croop and colleagues.
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.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Nurtec tablets disintegrating 75 mg. The submitted documentation does not support the medical necessity of the requested medication. The U.S. Food and Drug Administration (FDA) approves using Nurtec for abortive and preventive treatment of episodic migraines in patients aged 18 years and older, for which it has proven efficacy and safety data. The American Headache Society (AHS) supports the use of calcitonin gene-related peptide (CGRP) inhibitors only in patients aged 18 years and older. The American Academy of Neurology practice guidelines for the pharmacologic treatment of pediatric migraine prevention note that CGRP inhibitors are not a recommended treatment for the preventative treatment of migraine.
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.
Put this treatment in the complete diagnosis-and-drug graph, with the migraine-only denominator disclosed separately: migraine, CGRP drug and Botox denial evidence guide.
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 Nurtec, 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