Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine
Treatment: Ubrelvy 50 milligrams (mg) tablet
The insurer denied coverage for Ubrelvy 50 milligrams (mg) tablet
The denial is overturned

This case involves a young adult diagnosed with migraines, anxiety, attention deficit hyperactivity disorder, and Hashimoto's who was seen initially for follow-up regarding migraines. Prior relevant treatment included hydroxyzine, Fioricet/Fiorinal (without relief), and reported that migraine headaches were resolving with Excedrin Migraine. The patient reported at the time of the visit to have noticed a remarkable reduction in the frequency of migraines, getting 1 severe migraine associated with photophobia/phonophobia every few months. The medication list noted that active medications consisted of Nurtec 75 milligrams (mg), propranolol Hydrochloride (HCL) 10 mg, and Ubrelvy 50 mg. The patient was seen for consultation reporting relief with samples given of Ubrelvy. The patient claimed to have no relief with use of Nurtec with a document stating the patient was denied coverage of Ubrelvy as the patient was advised to try a triptan. The physician stated the patient had not tolerated selective serotonin reuptake inhibitors in the past and was therefore not an appropriate candidate for triptans. The report stated that when the patient was given propranolol 10 mg to be taken as needed before anxiety/panic attack, in addition to preventing anxiety/panic, the patient noted fewer headaches when taking the pill. The physician was recommending Ubrelvy 50 mg to be taken at the onset of headaches. The patient received a notice of adverse determination regarding Ubrelvy stating that criteria was not met as the patient must have tried and failed or have an intolerance to at least two preferred oral triptans. The patient does have a medical problem that prevents the use of triptans, and the patient has tried and did not improve after using Nurtec Oral Disintegrating Tablet (ODT). The medical notes state that patient tried but did not improve after Nurtec, with claims that the patient had not tried nausea improvement nor had an intolerance to two preferred oral treatments. The appeal submitted reiterated that the patient is unable to use triptans given that the patient experienced severe adverse effects while taking antidepressants and is therefore not a candidate for the use of triptans. The physician, therefore, recommended Ubrelvy as a safe and effective migraine treatment with very low to no side effects.  

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The Food and Drug Administration (FDA) notes that Ubrelvy is indicated for the acute treatment of migraine with or without aura in adults. The medical policy provided for the review states that in order to meet the criteria for the use of Ubrelvy, the patient must have a diagnosis of migraine headaches, had a previous trial and inadequate response to either amitriptyline or venlafaxine, or metoprolol, propranolol, atenolol, nadolol, nebivolol, or verapamil, or the following antiepileptic agents to include double product sodium, valproate sodium, topiramate, or gabapentin. Additionally, the patient must have a documented trial and failure or intolerance to at least 2 preferred oral triptans or documentation that the patient has a cardiovascular or known coronary vascular contraindication to the use of triptans and documentation that the patient has had a trial of and inadequate response or tolerance to Nurtec ODT or that the patient has had severe hepatic impairment. The documentation provided for the review stated that the patient had a history of migraines and was unable to take antidepressants to include oral triptans given prior adverse side effects from these medications. The patient previously tried Nurtec and propranolol with inadequate response. It is therefore determined that Ubrelvy would be appropriate for this patient. The request for Ubrelvy 50 mg tablet is medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Ubrelvy 50 milligrams (mg) tablet is substantiated.