Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Migraine headaches.
Treatment:  Nurtec ODT (oral disintegrating tablets) 75 mg (milligram) tablets.
The insurer denied coverage for Nurtec ODT (oral disintegrating tablets) 75 mg (milligrams) tablets.  
The denial is overturned.

The patient is a teenager diagnosed with migraines who is being recommended for Nurtec ODT 75 mg tablets. The patient received a letter denying coverage of Nurtec ODT, which stated that she did not meet age requirements set forth by the Food and Drug Administration (FDA) for the use of this drug and there was no literature to support use in the pediatric population. The patient's treating provider responded and noted that the patient had a high headache frequency and stated that she was unable to safely use triptans or non-steroidal antiinflammatorie drugs (NSAIDs) without developing medication overuse headaches. The physician stated that there were only 2 medications that do not cause medication overuse headache with frequent use. This included Nurtec and Ubrelvy. The physician listed the prior medications that the patient used for both acute treatment and for preventative therapy for migraines. The list included ibuprofen, Tylenol, Benadryl, ondansetron, rizatriptan benzoate, Cefaly, biofeedback, cyproheptadine, amitriptyline, nortriptyline, lamotrigine, magnesium oxide, propranolol, venlafaxine ER (extended release), fluoxetine, and Emgality.  In addition, the treating physician stated that there is supporting medical literature to justify a pediatric patient using Nurtec ODT.

There is scientific evidence in peer-reviewed literature supporting a result of improvement in health outcomes for patients using Nurtec ODT for treatment of migraines.

Nurtec ODT 75 mg tablets has final approval from the appropriate regulatory bodies for a diagnosis of migraines.

The patient is a good candidate for Nurtec ODT 75 mg tablets.

Based upon the provided information, Nurtec ODT 75 mg tablets is one of the best available treatments for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested medication is likely to be more beneficial than any of the standard treatments/procedures for this patient.

Current medical literature states that recommendations for the treatment of acute migraine in children and adolescents focused on the importance of early treatment, choosing the route of administration best suited to the characteristics of the individual migraine attack, and providing counseling on lifestyle factors that can exacerbate migraine, including trigger avoidance and medication overuse. Treatment for adolescent migraines includes lifestyle management, abortive medications, nonpharmacologic interventions such as cognitive behavioral therapy, and preventative medications if necessary.  

This patient has tried multiple acute and preventative treatment measures to help reduce the frequency and severity of migraine headaches. While she is just under the age limit set forth by the Food and Drug Administration for use of Nurtec ODT, the physician noted that she is over 5 feet tall and weighs at least 130 pounds and therefore is considered to have the stature of a full-grown woman. While the patient is not an adult, she would be a suitable candidate for the use of Nurtec ODT. The physician noted that there are only 2 medications that do not cause medication overuse headache with frequent use, and these are Nurtec and Ubrelvy. The patient is not able to safely use triptans or non-steroidal antiinflammatory drugs (NSAIDs) without developing medication overuse headaches.  It was therefore determined that Nurtec ODT would be appropriate for this individual.

In summary, the denial of Nurtec ODT 75 mg tablets and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.