Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine
Treatment: Nurtec ODT [oral disintegrating tablet] (rimegepant)
The insurer denied: Nurtec ODT (rimegepant)
The denial is upheld.

The patient is a teenage female with chronic migraines. Her medical history includes major depressive disorder, anxiety, borderline personality disorder, anorexia, attention deficit hyperactivity disorder, body dysmorphia, and dissociative episodes. Her migraines are debilitating. She has tried and failed Tylenol, magnesium oxide, co-enzyme Q10, Aimovig, propranolol, and Maxalt. She was given Nurtec samples to abort headaches. These samples were effective. She currently receives Cymbalta and trazodone. Her neurologist requested Nurtec as abortive treatment for her migraines.

The request for Nurtec was denied coverage by the health plan due to a minimum age requirement of 18 years of age. The requesting provider wrote a letter stating the patient has two migraines per week, for which Nurtec is effective and allows her to function. The other days she has milder headaches. This review is in regard to Nurtec use.

The requested Nurtec is not medically necessary.

Nurtec is a calcitonin gene-related peptide (CGRP) receptor antagonist. This medication is currently FDA (United States Food and Drug Administration) approved for the abortive or preventive treatment of migraines in patients 18 years and older.

A recently published review by the American Headache Society supports using CGRP (calcitonin gene-related peptide) inhibitors only in patients 18 years and older. CGRP (calcitonin gene-related peptide) inhibitors are not a recommended treatment for the preventative treatment of migraine by the most recent American Academy of Neurology practice guidelines (Oskoui). There is a recent publication from a special interest group within the American Headache Society providing expert level support for using CGRP (calcitonin gene-related peptide) inhibitors in patients below 18 years of age (Szperka). However, there are no completed controlled studies to provide efficacy or safety data in certain patients below 18 years of age to support this recommendation. In addition, the opinion expressed is of the members and does not represent the opinion of the American Headache Society. There is a retrospective study of CGRP (calcitonin gene-related peptide) inhibitors used for prevention of migraine in adolescent patients, which showed an improvement in the number of headache days and functioning compared to their baseline (Greene). However, the level of supporting data for efficacy is low as there was no control group. Thus, comparison to placebo could not be assessed. There is a phase III study on Nurtec (rimegepant) use in pediatric ages which is currently recruiting patients (Biohaven Pharmaceuticals). However, there is no data on abortive CGRP (calcitonin gene-related peptide) inhibitor/antagonist use in patients below 18 years of age (Slomski, Cohen).

In this case, the request for Nurtec was denied by the plan due to a minimum age requirement of 18 years old. As reviewed above, there is a lack of data to support use of this medication in patients below 18 years of age.

The requesting provider has stated that they cannot prescribe other first-line medications due to concerns of interactions with the patient's current psychiatric medications. The language and context in the letter are that this statement was in regard to preventative medications. The patient already receives Aimovig as a preventative agent (per the provided notes), and Nurtec was requested as abortive treatment.

There may be a need to closely monitor for serotonin syndrome with some of these of these certain medications, but there is no absolute contraindication. Therefore, given the above, as the patient is below 18 years of age and there is no data to support the use of this drug in this age range, Nurtec is not medically necessary.