Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headaches
Treatment: Aimovig Injection 140 MG/ML
The insurer denied the Aimovig
The determination is upheld.

The patient has a listed diagnosis of migraine headaches. It is unclear how such diagnosis was established. There is no detailed headache related history; its clinical characteristics, frequency and duration are not documented.
Notes by the provider indicate the patient is currently receiving Botox injections. The same note also indicates patient was taking frovatriptan, naratriptan, diclofenac, Relpax and Nurtec was added. Insurance forms add prior use of butalbital, which is recommended according to both the American Headache Society (Loder et al) and the American Academy of Neurology (Langer-Gould et al), to be avoided in the treatment of migraines given high risk of rebound. Despite such combined use, no evaluation for rebound headaches is documented.
Prophylactic treatments listed include amitriptyline at unknown doses; Depakote and Topamax. Notes indicate doses of Topamax were 50 milligrams (mg) once daily, and Depakote 500 mg once daily, both below the minimum recommended for migraine prophylaxis.
A patient appeal letter states Aimovig has been effective. It does not provide details regarding the diagnosis, the headache characteristics, or any prior treatment trial. At issue is the medical necessity of Aimovig.
The submitted medical records do not support a diagnosis of either episodic or chronic migraines, given lack of a detailed description of headache characteristics that would match any widely accepted diagnostic criteria such as the one from Headache Classification Committee of the International Headache Society listed below. Given the use of non recommended medications such as barbiturates as well as ongoing combinations of multiple different triptans, calcitonin gene-related peptide (CGRP) abortive agents, and other painkillers, the standard of care would include evaluation for rebound headaches which either did not occur or was not properly documented.
Records also do not support that proper first line migraine prophylactic agent trials have failed at accepted doses, for 8 weeks or longer, given lack of proper documentation. Amitriptyline trials have no documented details, and doses documented for both Depakote and Topamax are below recommended, and may not be considered proper failed trials, particularly in the presence of continued use of such painkillers with high risk of rebound headaches. Current standard of care recommends prolonged trials at appropriate doses of at least one anticonvulsant, one antidepressant, and one beta blocker, given the fact such drugs have a better known long term safety and efficacy profile than the newer CGRP blockers.
Additionally, the patient is reported to be currently on Botox. Botox use was an exclusion criteria for the CGRP trials including Aimovig. Therefore, safety and efficacy of combined use are currently unknown.
It should be noted that despite the patient's headaches being reported as complex and difficult to treat, the patient does not appear to have been evaluated by a neurologist, or any physician. Therefore, the records do not support medical necessity.

The determination is upheld.