Ubrelvy denials in California external review
In the California DMHC record, independent physician reviewers decided 18 published external-review cases involving Ubrelvyand overturned the plan’s denial in 94.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Migraine | 17 | 94.1% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ubrelvy 100 mg. The recent American Headache Society Consensus Statement reported that acute treatments considered effective for migraine include nonsteroidal anti-inflammatory drugs, nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations for mild-to-moderate migraine attacks. Migraine-specific agents such as calcitonin gene-related peptide (CGRP) receptor antagonists known as gepants are considered effective for moderate or severe attacks and mild-to-moderate attacks that respond poorly to nonspecific treatments. In a case report study by Mullin and colleagues, the authors evaluated the use of gepants and anti-CGRP monoclonal antibody (mAb) to be used concomitantly to treat refractory migraine.
Findings: The physician reviewer found that The patient has requested authorization and coverage for (1) the medication regimen, Ubrelvy 100 mg tablets (dispense 15 tablets per month for 12 months), or (2) the medication regimen, Ubrelvy 100 mg tablets (dispense 10 tablets per month for 12 months). The American Headache Society (AHS) notes that acute treatments considered effective for migraine in adults include nonsteroidal anti-inflammatory drugs (NSAIDs), nonopioid analgesics, acetaminophen, and caffeinated analgesic combinations such as aspirin,  acetaminophen , and  caffeine for mild-to-moderate attacks.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: At issue in this case is whether Ubrelvy tablets is medically necessary for the treatment of this patient. Findings: Multiple large, randomized, placebo-controlled trials have demonstrated efficacy of Ubrelvy. One study reported that demonstrated in 1672 subjects that 19.2% and 21.2% of the 50 and 100 mg, respectively, produced freedom from pain at two hours compared to 11.8% in the placebo group. Another study reported, a systematic review and meta-analysis of 64 randomized trials from showed that most triptan medications showed a higher odds ratio for pain freedom at two hours than ubrogepant (3.13 versus 1.38). A systematic review by the American Headache Society in 2015 determined there was level A evidence for multiple triptan medications and dihydroegotamine (study was before the release of ubrogepant).
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 Ubrelvy, 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