Diagnosis: Central Nervous System/Neuromuscular.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Reyvow.
The denial is overturned in whole.

The patient is a female with a longstanding history of migraine headaches. She has been under the care of a neurologist for at least six years (based on medical records) provided for review.
A note from a consult indicated that the patient had been seen for a headache evaluation on that date. The patient reported onset of headaches in her teenage years. The patient's headache frequency gradually increased over the years. With regard to acute treatments the records indicated that the patient had been ""on many different regimens of triptans including the Imitrex injections and Zomig nasal spray--all were not effective"). At the time of that visit the patient was prescribed a combination of eletriptan/dexamethasone/phenergan for the acute treatment of migraines.

At a follow-up visit the notes indicated that "Ubrelvy did not seem to help her headaches at all and Nurtec response has been variable. She has found Reyvow helpful when she takes it towards the end of the day and likes the fact that it makes her "sleep better" which she finds helpful when she has a migraine". At the time of that visit samples of Nurtec were given. The patient has since been prescribed Reyvow for the acute treatment of her migraines.

The health plan's determination is overturned.

In this case the patient is noted to have a history of aortic stenosis. While the rest of her cardiac history was not fully detailed the records provided for review, it would be within the generally accepted standards of practice to avoid the use of triptan agents.
As was noted in a recent review: "triptans are vasoconstrictors and these effects may increase the risk of serious ischemic events in patients who have underlying cardiovascular (CV) diseases or risk factors for CV disease" (Dodick et al 2020).
As such given the patient's history of aortic stenosis trials of almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan tablet, rizatriptan ODT, sumatriptan-naproxen, sumatriptan tablet, sumatriptan nasal spray, zolmitriptan ODT, zolmitriptan tablet would not be appropriate.
The records provided for review also indicated that the patient had trialed Ubrelvy but that the drug had not been effective for her condition (acute treatment of migraine).
The requested drug is a Selective 5-hydroxytryptamine (5-HT1F) receptor agonist which is noted to not carry the same cardiovascular risks that are associated with triptans (Rubio-Beltrán et al. 2018).
In this setting the requested non-formulary drug would be a more appropriate clinical choice (given the patient's failure of the plan's non-triptan preferred agent).