The only preventive that worked is $900 a month, and your insurer just called it 'not medically necessary.' Here's the appeal ladder, step by step.
The word buried in paragraph three
The letter comes in a plain envelope with the insurer's logo, and you skim past the greeting looking for the one phrase that decides your next three months: not medically necessary.
You already know what that phrase is hiding. You failed two triptans. You tried topiramate and couldn't finish a sentence on it. The CGRP inhibitor is the first preventive that cut your attack days in half, and the cash price is somewhere near nine hundred dollars a month. So the denial doesn't read like a medical opinion. It reads like a door.
Most people put the letter in a drawer and go back to rationing samples. That's the single most expensive thing you can do with it.
A denial is the opening position, not the ruling
Here's the handle for everything below: the first no is a form letter. It's generated by a utilization-management rule set, often before a human clinician has read a single line of your chart. The person who signed it may not be a neurologist. The reason code may be a template.
That matters because a system that denies by template can be overturned by evidence. An appeal isn't begging. It's forcing the plan to route your case to someone who actually has to justify the no in writing, against your documented treatment history and the FDA-approved indication for the drug. The letter is round one. You have three more rounds, and the odds swing hard in your favor as you climb.
Why 'they already said no' is the wrong read
The dominant reaction treats denial as a medical judgment about you. It usually isn't. It's a coverage-policy decision about a drug class, applied to a claim that didn't carry enough documentation to clear the plan's step-therapy gate on the first pass.
Step therapy is the real machinery here. Most commercial plans require you to have tried and failed a set number of older, cheaper preventives before they'll cover a CGRP monoclonal antibody or an oral gepant like atogepant or rimegepant. If your chart doesn't show those failures in the format the plan wants, dates, drug, dose, duration, and reason you stopped, the claim gets auto-denied. Nothing about your migraines changed. The paperwork did.
What the appeal ladder actually looks like
There are four rungs, and each has a deadline that starts ticking from the denial date. For ACA-regulated plans, you generally have 180 days to file an internal appeal, and the plan has a fixed window to answer. If the delay itself is harming you, you can request an expedited review that collapses those windows to roughly 72 hours.
The overturn rate is the part almost nobody acts on. Very few denied patients ever appeal, a fraction well under one percent on ACA marketplace plans, and a meaningful share of the ones who do appeal get the denial reversed. The plan is betting you won't climb the ladder. The table below is the ladder.
Rung
What it is
Deadline to file
Who decides
Decision window
1. Peer-to-peer
Your prescriber calls the plan's medical director directly
Before or alongside the formal appeal; no fixed statutory deadline
Plan medical director + your neurologist
Often same call or a few days
2. Internal appeal
Formal written request to reconsider, with records
Within 180 days of denial (ACA plans)
The plan, different reviewer than the denial
72 hrs urgent / Under ACA, internal appeal decisions must be made within 72 hours for pre-service claims and 60 days for post-service claim denials. ([source](https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/indexappealinghealthplandecisions))
3. Second-level internal
Only if your plan offers a two-tier internal process
Set by the plan's denial letter
The plan, senior reviewer
Per plan policy
4. External review
An independent third party outside the insurer
The federal floor is 180 days from the final internal denial to request external review under ACA standards. ([source](https://www.reddit.com/r/HealthInsurance/comments/1uivrda/insurance_denied_your_claim_as_not_medically/))
Independent Review Organization
45 days standard / 72 hrs expedited
ACA-regulated plan standards; deadlines are set by federal rule and restated in your denial letter. Self-funded employer plans follow a parallel federal track (see the caveat below).
Check whether your plan is self-funded first
If your coverage is a self-funded employer plan (ERISA), state external-review rules and state insurance-commissioner complaints don't apply the same way. You appeal through the plan and then a federal external-review path instead. Ask HR one question: 'Is our health plan fully insured or self-funded?' The answer changes which rung four you're standing on.
One denial, walked all the way through
Say the denial cites step therapy: you haven't documented two failed oral preventives. You pull your own records first. You've got a timeline showing you started propranolol in March, dropped it in May for fatigue, started topiramate in June, and stopped in August because of the word-finding trouble, plus your monthly attack counts before and after each.
Rung one, your neurologist requests a peer-to-peer and reads that timeline aloud to the plan's medical director. If that doesn't clear it, rung two: a written internal appeal that attaches the same timeline, the FDA-approved indication for the drug, and a medical-necessity letter from your prescriber. Most cases end here. If the plan still upholds the denial, you request external review, and an independent organization with no financial stake in the no looks at the identical file. The thing that carries you up every rung is the same: a clean, dated record of what you tried and exactly why it failed.
If the denial is beatable, the record is the weapon
Change the read on the letter and the whole calculus changes. The appeal stops being an emotional confrontation and becomes an evidence-assembly problem, and evidence is the one variable you control.
Every reviewer up the ladder is asking a version of the same question: does this person's history meet the criteria for this drug? A denial usually means that history existed but wasn't captured in a form the plan could read. So the reader who keeps a continuous, dated symptom-and-medication record isn't just tracking for themselves. They're building the exact exhibit that overturns a denial.
The record you needed before the letter arrived
This is where tracking earns its keep for something other than your own reference. The CGRP Prior-Auth Letter Builder at postdrome.app/tools/cgrp-prior-auth-letter/ drafts the medical-necessity letter that seeds rung one, and it's only as strong as the history behind it: which preventives, what doses, how long, why you stopped, and what your attack frequency did in response.
That's the record Postdrome is built to hold. Not the headache alone, but the full arc, the residual photophobia, the brain fog, the days lost after the pain lifts, logged continuously so a step-therapy timeline isn't something you reconstruct from memory the week a denial arrives. Aura Mode exists precisely because the hard days to log are the ones that matter most on paper. When the plan wants dates and durations, you export them instead of guessing.
The plan is betting you won't climb the ladder. A dated record is how you take that bet away from them.
What we're watching next
Two things are shifting under this. Several large commercial plans have been quietly loosening step-therapy requirements for the CGRP class as the drugs come off patent-cliff exclusivity, and the oral gepants are changing which failures a plan will accept before it approves. We're tracking those policy changes as they land, in plain language, because the criteria that got you denied this year may not be the criteria next year. If your denial cites a rule, it's worth checking whether that rule still stands before you assume the no is permanent.
Start the record your appeal will need. Track the full arc with Postdrome.
We can't fix your insurer's appeal process. We can make sure that when a reviewer asks for dates, doses, and durations, you have the continuous record ready to export instead of rebuilt from memory. Postdrome logs the full attack arc, including the postdrome days most apps drop, so the timeline behind your appeal holds up.
