Prior Preventive Failure Documentation — What Reviewers Actually Look For
Step therapy denial is the most common preventable PA failure — reviewers need four data points per trial: agent, dose achieved, duration, and reason for stopping.
PA impact: This card directly affects prior authorization outcomes. Documentation language from this card can be used in PA letters and appeals.
Why details matter. Step therapy denial is the most common preventable PA failure. A reviewer evaluating a CGRP preventive request needs four data points for each prior preventive trial: medication name, dose achieved, duration, and reason for stopping. Missing any one of them is grounds for denial. "Patient tried topiramate" fails. "Patient completed 12 weeks of topiramate 100mg daily, discontinued due to cognitive impairment affecting work performance" passes.
What an adequate trial looks like. The standard for an adequate preventive trial is 8 weeks at therapeutic dose. Both halves of that standard matter independently — 8 weeks at a sub-therapeutic dose does not count, and a therapeutic dose discontinued at 4 weeks does not count. For topiramate, therapeutic dose is 100–200mg daily. For propranolol, 80–240mg daily. For amitriptyline, 50–150mg daily. For valproate, 500–1500mg daily. If the patient could not reach therapeutic dose due to side effects, document the highest dose achieved, the limiting side effect, and why further titration was not possible.
When to skip step therapy entirely. Documented contraindications bypass step therapy when explicit in the chart. Common grounds: cardiovascular contraindications to beta-blockers (bradycardia, heart block, significant hypotension), teratogenicity concerns with topiramate or valproate in women of childbearing age (document pregnancy intent or reproductive age plus inadequate contraception), and documented allergy or prior serious adverse reaction. Each of these must be stated specifically, not implied.
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Run a PA — free →Citations: AHS Consensus 2021 — Ailani J et al., Headache 2021;61(7):1021-1039. doi:10.1111/head.14153 | AAN Quality Standards Subcommittee — Silberstein SD et al., Neurology 2012;78(17):1337-1345.