Neurology denials: appealing migraine biologics, Botox, and infusion therapies

Denials in neurology center on CGRP inhibitors and other migraine preventives (gated behind a documented trial of older agents), onabotulinumtoxinA for chronic migraine (gated by headache-frequency criteria), and infusion therapies such as IVIG and multiple-sclerosis disease-modifying treatments (gated by diagnosis and step-therapy criteria). The clinical case usually meets AAN guidance — the denial fires when the prior-therapy trail, the headache-day count, or the diagnostic criteria aren't mapped to the plan's specific policy.

Why these denials happen

Plans require a documented trial and failure of older oral preventives before a CGRP therapy; for onabotulinumtoxinA in chronic migraine they require documentation of the headache-frequency threshold the trials used; and for IVIG or MS infusions they require the diagnosis, supporting studies, and a step-therapy or preferred-agent trail. AAN guidance supports these therapies for the appropriate patients, so the denial is generally a documentation gap rather than a dispute over whether to treat.

The common denials

• CGRP migraine therapy denied for step therapy — trial/failure of older oral preventives not documented.
• OnabotulinumtoxinA denied — the chronic-migraine headache-frequency criteria not documented.
• IVIG denied — the qualifying diagnosis or supporting lab/electrodiagnostic studies not established.
• MS disease-modifying therapy denied for a non-preferred agent without rationale.
• Reauthorization denied — ongoing response or continued necessity not re-documented.

Is it worth appealing?

How to appeal

1. 1

   Document the prior-therapy trail

   For CGRP and other preventives, show the trial, failure, intolerance, or contraindication of the older agents the plan requires — a contraindication counts as a met step.

2. 2

   Establish the protocol criteria

   For onabotulinumtoxinA, document the headache-frequency threshold; for IVIG and MS therapies, document the diagnosis and the supporting studies the policy names.

3. 3

   Cite AAN guidance and the plan's policy together

   Map the diagnosis, severity, and prior therapy to both the AAN recommendations and the plan's specific prior-auth criteria.

Frequently asked

Clinical-coverage patterns and guideline references are summarized for plain-language reference and vary by plan and payer policy. This is general information for clinicians and billing staff, not medical, legal, or coding advice — confirm against the governing coverage policy and the current guideline for each claim.