Neurology Prior Authorization and Denial Guide

Prior authorization requirements, payer-specific denial patterns, and appeal frameworks for neurological services: MS disease-modifying therapies, CGRP inhibitors for migraine, neurological imaging, EEG, EMG/nerve conduction studies, and deep brain stimulation. Grounded in Aetna CPBs for neurological conditions, UHC CDG Neurology, Cigna MCPs, ECTRIMS/AAN MS treatment guidelines, and AAN headache clinical practice guidelines.

Multiple sclerosis disease-modifying therapies require prior authorization from all major commercial payers. Documentation requirements include the MS diagnosis confirmed by McDonald Criteria (2017 revision), MRI imaging showing demyelinating lesions, neurological exam findings, and for high-efficacy agents (natalizumab, ocrelizumab, ofatumumab, cladribine), documentation of either inadequate response to a first-line agent or clinical and imaging features warranting early high-efficacy therapy. CGRP inhibitors (erenumab, fremanezumab, galcanezumab, eptinezumab) require prior authorization and documentation of 4 or more migraine days per month and failure of 2–3 preventive medication classes.

Deep brain stimulation (CPT 61867–61868) requires prior authorization from all payers. Aetna and UHC coverage criteria for DBS in Parkinson's disease require documentation of 5 or more years of Parkinson's diagnosis, adequate response to levodopa with medication-refractory motor fluctuations or tremor, and neuropsychological testing excluding significant cognitive impairment. Medicare follows NCD 160.24 for essential tremor and Parkinson's disease indications.

• All specialty guides
• Appeal Letter Builder — neurology denial appeals
• Denial Decoder