David Fights Back Against Mandatory Step Therapy for Migraines
David R., a 38-year-old college professor, suffered from chronic, debilitating migraines. After years of trying various oral medications with limited success and painful side effects, his neurologist prescribed a modern, highly effective CGRP inhibitor injection.
The relief was immediate. However, when his insurance renewed, he was denied coverage. The insurer mandated "Step Therapy," requiring him to fail two generic, older treatments he had already proven ineffective years ago. The denial letter stated: "Patient must use Preferred Formulary drugs first." The yearly cost of the injectable therapy was approximately $15,000.
David used the Counterforce Health tool to prepare his appeal.
How Counterforce Health Stepped In:
- Prior Failure Documentation: David uploaded his denial letter and past medical notes documenting his failed trials of the older, generic medications.
- Clinical Exemption Argument: The platform recognized the Step Therapy denial and auto-generated an appeal that focused on continuity of care and clinical rationale. It cited guidelines from the American Academy of Neurology (AAN), arguing that disrupting a stable, high-efficacy treatment violates the standard of care.
- The Result: The system drafted a concise, targeted appeal that included a clear timeline of his previous treatment failures. The insurance company approved an exception to the Step Therapy rule, restoring the $15,000 annual coverage within four business days.
David maintained stability and avoided a painful relapse. "My doctor was too busy to write an exhaustive historical defense," David said. "Counterforce created a perfect, data-driven argument that proved I had already stepped and failed through their mandatory hoop."