Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Migraines

Treatment: Zolmitriptan 5 milligram (mg) Oral Release Tablet Dispersible (OR TBDP), up to 12 tablets every 30 days

The insurer denied coverage for Zolmitriptan 5 milligram (mg) Oral Release Tablet Dispersible (OR TBDP), up to 12 tablets every 30 days

The denial is modified.

This case involves a patient with a history of migraine headache who is being recommended for zolmitriptan.  The patient was seen for follow-up regarding migraines.  The patient reported 3 "unique" headaches each month over four months.  Since then, the patient was doing better with their headache log considered busy but lower in severity.  At the time of the visit, the patient was using naproxen, nortriptyline, Emgality, and Zofran for nausea.  Abortive therapy included ibuprofen, Tylenol (which the patient claims was ineffective), Excedrin Migraine, rizatriptan (which caused side effects of sleepiness), naproxen, Zofran, and was prescribed Zolmitriptan.  For prophylactic therapy, the patient had taken fluoxetine, topiramate, propranolol, nortriptyline, and Emgality.  The document noted that the patient was advised to try Nurtec if needed (as it does not cause medication overuse headache and can be used once daily).  The physician noted that Ubrelvy was the patient's preferred insurance medication and the patient may have to switch to that drug.  In the interim, the patient was advised to continue Emgality.  A letter stated the physician was requesting coverage of Zolmitriptan 5 milligram (mg) tablets for acute treatment of migraine.  

The physician stated the patient easily meets International Classification of Headache Disorders-3 (ICHD3) criteria for chronic migraine with 4-6 migraine attacks per month lasting 4 or more hours each described as throbbing/pounding pain, nausea, with photophobia and phonophobia.  The limited 6 Zolmitriptan tablets per month is insufficient to treat 4-6 migraine attacks per month because Zolmitriptan sometimes requires redosing to work sufficiently.  The author of the letter was noted to be a headache medicine physician and is aware of the dangers of medication overuse headaches.  The physician stated that it takes at least 10 triptan doses per month for 3 months to do that and therefore the policy's quantity limit of 6 tablets/month is excessively restrictive and unreasonable.  

The Food and Drug Administration (FDA) states that Zolmitriptan is indicated for acute treatment of migraine with or without aura in adults.  The FDA recommends a starting dose of 1.25 mg or 2.5 mg with a maximum single dose of 5 mg.  Patients may repeat the dose after 2 hours if needed not to exceed 10 mg in any 24-hour period.  The documentation provided for the review noted that the patient was suffering from migraines and had tried multiple medications to help control symptoms.  The physician was requesting more than the limit of 6 zolmitriptan tablets per month set by the drug formulary. Therefore, while the dispute pertains to Zolmitriptan 5 mg or TBDP, up to 12 tablets every 30 days, the recommendation is to approve 10 tablets of Zolmitriptan to treat the patient's migraines.  As such, Zolmitriptan 5 mg tablets, quantity 10 in a 30 day period is medically necessary.

Based on the above, the insurer's denial must be modified. 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 Zolmitriptan 5 milligram (mg) OR TBDP, up to 12 tablets every 30 days services is not substantiated. However, while the dispute pertains to Zolmitriptan 5 mg or TBDP, up to 12 tablets every 30 days, the recommendation is to approve 10 tablets of Zolmitriptan to treat the patient's migraines.