Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intractable migraine without aura. 
Treatment: Aimovig. 

The insurer denied coverage for Aimovig. 

The denial is upheld. 

This patient was diagnosed with chronic intractable migraine without aura.  The patient was seen for a follow-up.  At that point, it was estimated that the patient was getting headaches every other day.  She endorsed severe headaches once or twice a week.  She reported that she was doing the same.  She was on nortriptyline 50 mg (milligrams) at night.  She tolerated the medication well with no side effects.  Zolmitriptan had not been effective.  Nurtec, Qulipta, and Emgality had been denied by insurance.  The patient had previously utilized nortriptyline, Ajovy, Migrelief, and propranolol.  For abortive medication she had trialed Maxalt, Zolmitriptan, ibuprofen, Excedrin Migraine, Ubrelvy, and naproxen.  The patient started having headaches in middle school.  They escalated in frequency and intensity over the last couple of years.  The severe headaches were associated with phonophobia, photophobia, and nausea without vomiting.  There was a family history of migraines.  The provider recommended Aimovig and starting propranolol. 

Aimovig is not considered medically necessary for this patient. 

The Food and Drug Administration states that Aimovig is indicated for the preventative treatment of migraines in adults.  Per the Food and Drug Administration, it is not known if Aimovig is safe and effective in children.  The additional cited literature notes that the pediatric headaches impact up to 80% (percent) of children, many recurrently, by the time they are adolescence years old. Preventing the progression of episodic chronic headache results in less truancy, staying current with schoolwork and improves children's quality of life.  In pediatric migraine patients, plasma levels of CGRP (calcitonin gene-related peptide) are elevated during migraine attacks, suggesting that CGRP likely plays an important role in pediatric migraines as well.  However, research is ongoing for the safety and efficacy of the treatment in children. 

The available Food and Drug Administration recommendation for preventative migraine treatment is Topamax.  The decision to start preventive treatment since it is multifactorial and should be initiated after thorough discussion patient and caregivers about related risks and benefits of treatment.  In this case, the patient endorsed ongoing migraine headaches.  She reported headaches every other day with severe headaches once or twice a week.  She had utilized nortriptyline, Zolmitrptan, Ajovy, and Migrelief.  She had recently started propranolol with reported baseline dizziness.  The patient's insurance had denied Nurtec, Qulipta, and Emgality.  She had utilized Zolmitriptan, ibuprofen, Excedrin Migraine, Ubrelvy, and naproxen.  Trokendi was contraindicated due to the patient's depression.  The documentation did not identify that the patient had failure of topiramate which is recommended for young adult patients and older patients per the Food and Drug Administration.  Given the lack of established literature support for the requested medication for the patient's clinical presentation and lack of failure of guideline recommended treatments, the medical necessity of the treatment has not been established. 

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient. 

The insurer's denial of coverage for Aimovig is upheld. Medical necessity is not substantiated.