Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines.
Treatment is Ajovy.
The insurer denied coverage for Ajovy.
The denial is upheld.

According to the medical records, the patient is a female. The patient was seen for evaluation of headaches. The doctor noted that the patient suffered from headaches 3 days per week. In the impression he noted the chronic migraine and that the plan was to start Candesartan and magnesium. The patient was seen by another doctor for a follow-up regarding headaches. She noted that the patient had dizziness and heart racing on Candesartan. She noted that the patient complained of having 2 days of headaches per week. She noted that the patient was on Nurtec as needed. She noted that the plan was to taper off Candesartan and start Ajovy.  An appeal letter noted that the patient could not use beta blockers or calcium channel blockers as she is on Candesartan. She noted that the patient could not also use topiramate.

The patient can be tried on antidepressants before going on CGRP (Calcitonin gene-related peptide) blockers. Therefore, the health care plan acts reasonably and with sound medical judgment and is in the best interest of the patient.      

Ajovy is not considered medically necessary for this patient. The patient can be tried on tricyclic antidepressants before going on Ajovy.

According to Kahriman, A. et al. (2018), "Migraine and tension-type headache (TTH) are common primary disorders that carry significant morbidity and socioeconomic effect. In this article, we will review the epidemiology, presentation, and diagnosis of these disorders. First-line acute treatment for migraine consists of analgesics, triptans, and antiemetics, while nonsteroidal anti-inflammatory drugs are the mainstay treatment for TTH. Patients with frequent or chronic headaches warrant prophylactic therapy. For migraine, various classes of preventives can be used (-blockers, tricyclics, antiepileptics, botulinum toxin), with the choice of therapy tailored to the patient's risk factors and symptoms. For TTH, tricyclics have the most evidence as prophylactic therapy. A new class of medication, monoclonal antibodies to calcitonin gene receptor peptide or its receptor, became available in 2018 and is the first class of medication specifically designed to treat migraine. In addition to pharmacotherapy, we will also review nonpharmacologic interventions as well as neuromodulation for migraine."Lastly, as per Up to Date "For most patients with episodic migraine (<=14 headache days per month) who indicate preventive therapy (see 'Indications' above), we suggest initial treatment with amitriptyline, venlafaxine, one of the beta blockers (metoprolol or propranolol), or topiramate. Approximately half of the patients given any of these drugs will have a 50 percent reduction in the frequency of headaches, but the doses required may lead to intolerable side effects [8]. The choice among preventive agents of similar efficacy should be individualized according to patient-specific characteristics, comorbid conditions, medication side effect profile, medication cost, and patient values and preferences [9-11].
The calcitonin gene-related peptide (CGRP) antagonists are reasonable options for patients with marked disability from frequent migraine who do not respond to or cannot tolerate other options [12]."

Based on the above, the insurer's denial is upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Ajovy services is not substantiated.