Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Migraine headaches.
Treatment:  Nurtec ODT (oral disintegrating tablets) 75 mg (milligram) tablets.
The insurer denied coverage for Nurtec ODT (oral disintegrating tablets) 75 mg (milligrams) tablets.  
The denial is overturned.

This is a teenager who suffers from severe intractable migraines headaches and has failed all of the available prophylactic medications agents. These agents include, Lamotrigine, Nortriptyline, Amitriptyline, Propranolol, Emgality, Magnesium, venlafaxine, and Fluoxetine. The patient's migraines are very frequent and she cannot take safely abortive therapies, including Triptans and non-steroidal anti-inflammatory drugs (NSAIDS), around the clock and requires an effective Migraine prophylactic medication.   

Although Nurtec, working with the same biochemical mechanism as Emgality has not yet been approved in the management of Pediatric patients, there are ongoing studies being done to determine the efficacy and safety of the use of these medications in the pediatric population. 

There are numerous anectodical reports that Nurtec is safe to use in pediatric patients. 

There are studies included in the appeal letter written by the patient's treating physician, which suggest that this agent is safe to use in Pediatric patients. 

Nurtec is Food and Drug Administration (FDA) approved for its use in patients suffering from a diagnosis of Migraines. 

There is a greater benefit for this patient to be prescribed Nurtec as a prophylaxis medication considering that she has failed numerous preventative agents for the treatment of migraines and the fact that this patient requires taking a very large amount of abortive medications to manage the high frequency of her migraines.

The fact that this patient tolerated Emgality; it is highly unlikely that this patient will experience any adverse reaction to the treatment with Nurtec. 

There is scientific evidence in peer-reviewed literature supporting a result of improvement in health outcomes for patients using Nurtec ODT for treatment of migraines.

The patient is a good candidate for Nurtec ODT 75 mg tablets.

Based upon the provided information, Nurtec ODT 75 mg tablets is one of the best available treatments for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested medication is likely to be more beneficial than any of the standard treatments/procedures for this patient.

There is more benefit than risk for this patient to be prescribed Nurtec for Migraine prevention. Based on the review of the available literature on the subject, that in view of this patient's failure of numerous preventative migraine medications (prophylactic  therapy) and weighing the risk of this patient being managed with daily abortive therapies versus using Nurtec for prophylaxis.

In summary, the denial of Nurtec ODT 75 mg tablets and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.