Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headaches
 
Treatment: Ajovy

The insurer denied Ajovy. The denial was upheld.  

This patient is a young male who presented to the provider's office in mid-2019.  The patient was being seen for headaches.  The records indicated that the patient had mild occasional headaches since the middle childhood, and they started getting more frequent, and intense, when he was an adolescent.  For approximately a year to a year and a half, they have been occurring constantly.  Bright lights, noise, stress, and heat could trigger the headaches.  Sometimes the headaches were associated with either bright spots or an inability to see certain areas of visual fields during his headache, and last for a minute or 2.  The headaches were frontotemporal and halocephalic in location, and sharp, or pounding in quality.  They were rated 6/10, but get to 9/10 3 or 4 times per week.  The headaches were continuous in duration, and never went away.  They were associated with photophobia, phonophobia, nausea without vomiting, dizziness, and drowsiness.  The patient had been trialed on topiramate and was titrated up.  It was discontinued due to ineffectiveness.  The patient had been started on amitriptyline and he was on it for over a year.  The patient had anxiety, anger, irritability, and excessive somnolence, as a side effect, so it was discontinued.  The patient was started on fluoxetine in early 2019.  The patient was on 10 mg/day with slight improvement in headaches.  They were still continuous.  The patient was utilizing Fioricet once a week, but he used to take it daily for 6-8 months; the patient stopped it in early 2019.  The patient was also using Aleve 2 tablets 2-3 times per week, in addition to Fioricet.  He tried Tylenol 650 mg and ibuprofen 400 mg, with no significant response and has never tried Excedrin or a triptan. He missed 15 days of school due to his headaches. The provider opined that the patient had likely chronic migraine headaches with and without visual aura, with medication overuse headache, given the patient's history, family history and neurologic examination.  The patient's mother, maternal grandmother and maternal uncle had headaches.  The Magnetic Resonance Imaging (MRI) of the brain was normal.  The provider recommended treatment with Ajovy.

Although it was not documented how long the patient had utilized the medications that have been trialed, including amitriptyline, topiramate, and fluoxetine the patient had trialed medications from 2 different classes.  Amitriptyline and topiramate are from two different drug classes and these medications are used for migraine headaches. The patient had not utilized triptans.  According to current literature this medication has been US Food and Drug Administration (FDA) approved for the prevention of migraine headaches in adults.  While the medical literature supports the use of Ajovy for adults, the medical literature failed to support the safety and efficacy in use of Ajovy for pediatric patients.  Further clinical trials are necessary.  

Based on the above, the medical necessity for Ajovy not substantiated.  The insurer's denial is upheld.