The reference your practice needs to get CGRP prior authorizations right the first time.

DIAGNOSIS:
Primary: Chronic Migraine without aura, not intractable (G43.709)
Average headache days/month (past 3 months): [NUMBER] (threshold: ≥15)

REQUESTED MEDICATION: [CGRP AGENT, DOSE, ROUTE, FREQUENCY]
  Options: Erenumab (Aimovig) | Fremanezumab (Ajovy) | Galcanezumab (Emgality) | Eptinezumab (Vyepti)

MEDICAL NECESSITY:
- Chronic migraine confirmed (≥15 headache days/month ≥3 months)
- Functional impairment: MIDAS Grade [GRADE]; HIT-6 [SCORE]
- Failure of ≥2 oral preventive drug classes (documented below)

FAILED PREVENTIVE TRIALS:
1. [CLASS: e.g. Beta-blocker] — [Drug], [DOSE], [MONTHS] months — [Reason failed]
2. [CLASS: e.g. Tricyclic] — [Drug], [DOSE], [MONTHS] months — [Reason failed]
3. [CLASS: e.g. Anticonvulsant] — [Drug], [DOSE], [MONTHS] months — [Reason failed]

CURRENT ACUTE USE: [MEDICATIONS] — [DAYS] days/month — MOH: [YES/NO]

CLINICAL SUMMARY:
[PATIENT] is a [AGE]-year-old with chronic migraine (G43.709) who has failed [NUMBER]
oral preventive classes over [YEARS] years. Initiation of [AGENT] is medically necessary.

DIAGNOSIS: Chronic Migraine (G43.709 / G43.719)
Headache days/month: [NUMBER] (≥15) | Migraine days/month: [NUMBER] (≥8)

MIDAS DOMAIN-LEVEL ASSESSMENT (required by Noridian MAC — Feb 22, 2026):
Domain A — Missed work/school days (past 3 months): [NUMBER]
Domain B — Days with reduced work/school productivity: [NUMBER]
Domain C — Missed household work days: [NUMBER]
Domain D — Days with reduced household productivity: [NUMBER]
Domain E — Missed family/social/leisure activity days: [NUMBER]
MIDAS Total: [SCORE] — Grade [I / II / III / IV]

LCD COMPLIANCE (DL39909):
[ ] ≥15 headache days/month for ≥3 months, ≥8 of which are migraine
[ ] ≥2 oral preventive drug class failures documented
[ ] MOH absent or managed | [ ] PREEMPT protocol

FAILED ORAL PREVENTIVES:
1. [Class]: [Drug], [DOSE], [MONTHS] months — [Reason failed]
2. [Class]: [Drug], [DOSE], [MONTHS] months — [Reason failed]

REQUESTED: OnabotulinumtoxinA [155–195] units per PREEMPT protocol, Q12W
Cycle #: [NUMBER] | Prior response: [≥50% reduction / partial / first cycle]

DIAGNOSIS: [G43.709 / G43.009 / G43.109]
CURRENT ACUTE USE: [MEDICATIONS] — [DAYS] days/month — MOH: [Not present / Present]

STEP THERAPY:
Step 1 — Triptan: [DRUG, DOSE, ROUTE] | Duration: [MONTHS] months
  Response: [Adequate / Inadequate] | Adverse effects: [None / Specify]

Step 2 — Second triptan (if Step 1 inadequate): [DRUG, DOSE, ROUTE]
  Response: [Adequate / Inadequate]

Step 3 — Gepant (if triptans failed or contraindicated):
  [Rimegepant 75mg / Ubrogepant 50mg or 100mg]
  Rationale: [Triptan contraindicated / Two failures / Intolerable side effects]

Step 4 — Ditan (if gepant also failed): Lasmiditan [dose]
  Rationale: [SPECIFY — CNS/driving warning documented]

QUANTITY LIMIT (if requesting above standard):
Attacks/month: [NUMBER] | Doses/attack: [NUMBER]
Clinical rationale: [BASIS FOR ABOVE-STANDARD QTY]

RESCUE: [Ondansetron / Prochlorperazine / Ketorolac / DHE / Other]

REFERRAL TO: [General Neurology / Headache Specialist / Specific provider: NAME]
DIAGNOSIS: [ICD-10: G43.709 / G43.009 / G43.719 / G44.009 / other]

REASON FOR REFERRAL:
[ ] Refractory chronic migraine — ≥3 failed preventive classes
[ ] CGRP mAb initiation/monitoring
[ ] Botox initiation (LCD DL39909)
[ ] PA appeal — specialist documentation requested
[ ] Other: [SPECIFY]

CLINICAL SUMMARY:
[PATIENT] is a [AGE]-year-old with [DURATION]-year history of [DIAGNOSIS].
Headache days/month: [NUMBER] | MIDAS Grade [GRADE] | HIT-6: [SCORE]
Failed preventives: [NUMBER classes] | Acute use: [DAYS] days/month
Imaging: [result or "None"] | Comorbidities: [LIST]

SPECIFIC QUESTIONS FOR SPECIALIST:
1. [QUESTION]
2. [QUESTION]

URGENCY: [Routine / Soon (4–6 wk) / Urgent]

YOUR NEW MEDICATION:
[Aimovig / Ajovy / Emgality / Vyepti] — [DOSE] — [Monthly / Quarterly]
Given: [Self-inject at home / In clinic / Infusion center] | First dose: [DATE]

WHAT TO EXPECT:
Months 1–3: Most patients need 2–3 months to notice meaningful change.
  Keep using your acute medications as needed.
Month 3: Headache diary review determines reauthorization
  (goal: ≥50% reduction in headache days).
No response by month 3: We will discuss switching to a different CGRP agent.

TRACK EVERY DAY — including headache-free days.
Track at: headachevault.com / paper diary / Migraine Buddy

[DELETE FOR MEDICARE/MEDICAID — not applicable]
Copay assistance: Manufacturer cards available for commercial insurance.
[END DELETE]

CONTINUE YOUR ACUTE MEDICATION: [MEDICATION] as needed.
Alert: Contact us if using >10–15 days/month.

SIDE EFFECTS: Injection site reaction; constipation (Aimovig most common).
EMERGENCY: Hives, breathing difficulty → call 911.

WHAT HAPPENED: Botox injected at [NUMBER] sites (PREEMPT protocol) for chronic migraine.
How it works: Blocks neurotransmitters in migraine pathway. Effect builds gradually.

12-WEEK CYCLE: Next injection date: [DATE].
Do not miss — late injections affect insurance coverage.

NEXT 4 HOURS — RESTRICTIONS:
Do NOT: lie down | massage sites | exercise strenuously | apply heat

FIRST 2 WEEKS: Soreness and temporary headache worsening are normal (days 1–3).
Improvement builds from week 2.

INSURANCE STOPPING RULE: Requires ≥50% reduction in headache days by cycle 2–3.
Track every day — headachevault.com / paper diary / Migraine Buddy

ACUTE MEDS: Continue [MEDICATION] for breakthrough headaches.
SIDE EFFECTS: Bruising/soreness (resolves). Eyelid droop (rare, resolves).
EMERGENCY: Swallowing/breathing difficulty → call 911.

YOUR ACUTE MEDICATIONS:
[MEDICATION 1] — [DOSE] — take at first sign of migraine
[MEDICATION 2] — [DOSE] — [INSTRUCTIONS]
Rescue: [MEDICATION] — if primary fails

MONTHLY LIMITS:
[MEDICATION 1]: no more than [NUMBER] days/month
[MEDICATION 2]: no more than [NUMBER] days/month

[==== DELETE IF MOH NOT APPLICABLE ====]
⚠ MEDICATION OVERUSE HEADACHE (MOH):
Using triptans >10 days/month or analgesics/NSAIDs >15 days/month can cause
daily headaches (MOH). Signs: headaches >15 days/month, waking with headache,
medication working less well.
Your current use ([NUMBER] days/month) is [approaching / at] the threshold.
[==== END DELETE ====]

MONTHLY TARGET: ≤[NUMBER] days of acute medication use.
TRACK DAILY: headachevault.com / paper diary / Migraine Buddy

GO TO ED IF: Worst headache of life | Fever + stiff neck | Post-trauma |
New neuro symptoms | >72-hour attack

YOUR RIGHTS WHEN A PA IS DENIED:

1. Right to appeal: First-level (internal) → second-level → external independent review.
   Do not accept denial without appealing.

2. Step therapy override: You may qualify if you previously failed required medications,
   they are contraindicated, or you are stable on a working medication.
   Our office can file the override request.

3. THE HEADACHE Act (H.R. 5536):
   Would set standards for PA decisions affecting headache patients.
   Contact your rep: house.gov/representatives/find
   Message: "I support the HEADACHE Act (H.R. 5536)."

HEADACHE ON THE HILL: Annual advocacy event — patients meet directly with Congress.
Learn more: allianceforheadacheadvocacy.org

APPEAL DOCUMENTATION WE WILL SUBMIT:
[ ] Clinical letter | [ ] MIDAS and HIT-6 scores | [ ] Headache diary data
[ ] Peer-reviewed evidence | [ ] Step therapy override request (if applicable)

RESOURCES: americanmigrainefoundation.org | allianceforheadacheadvocacy.org
PA Tool (free): headachevault.com/pa

WHY IT MATTERS: Your diary documents headache frequency (required by insurance
for CGRP/Botox), treatment response (≥50% reduction is the reauth threshold),
and MIDAS/functional impact for PA letters.

TRACK EVERY DAY — EVEN HEADACHE-FREE DAYS:
1. Headache? Yes / No
2. Severity: Mild (1–3) / Moderate (4–6) / Severe (7–10)
3. Functional impact:
   Level 1 — Minimal: normal activity
   Level 2 — Mild: most activities ok
   Level 3 — Moderate: difficulty with some activities
   Level 4 — Severe: must rest; many activities not possible
   Level 5 — Debilitating: bed rest; unable to function
4. Medication: which one(s) and how many doses
5. Triggers: sleep, stress, food, weather, hormones (optional)

HOW TO TRACK:
- Headache Vault (recommended): headachevault.com — free
- Paper diary: ask our office
- Migraine Buddy: export data and bring to appointments

BRING: 30 days of complete daily data to every appointment.