Nurtec Odt denials in California external review
In the California DMHC record, independent physician reviewers decided 12 published external-review cases involving Nurtec Odtand overturned the plan’s denial in 100%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Nurtec Odt denials
| Category | Decisions | Overturned |
|---|---|---|
| Migraine | 8 | 100% |
| Chronic Migraine | 4 | 100% |
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: A patient has requested authorization and coverage for (1) brand-name Lyrica and (2) an additional four tablets of Nurtec ODT per 30 days.The records document a history of fibromyalgia and complex regional pain syndrome with neuropathic pain that has been effectively managed with brand-name pregabalin (Lyrica), allowing maintenance of function and continued employment. The records further document that treatment with generic pregabalin resulted in adverse effects, worsening headache, migraine symptoms, neck pain, back pain, and foot pain. Interruption of pregabalin therapy also resulted in severe pain and functional decline. Treating providers documented improved symptom control and tolerability with brand-name Lyrica compared with generic formulations.
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 Odt, 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