Diagnosis: Acute Migraines

Treatment: Ubrelvy

The insurer denied coverage for Ubrelvy.

The denial is upheld.

This case involves a female patient who has been recommended to utilize Ubrelvy due to ongoing headaches. The documentation indicated she was complaining of headaches. The documentation indicated she will typically get migraine around the time of her menstruation. She sometimes can have them other times as well. She states she typically has 2-6 headaches a month. They may be associated with nausea, occasional vomiting, photo and phonophobia. She has presented to the Emergency Department 3 times for her headaches. The documentation detailed her migraines began after she was diagnosed with Cushing's disorder and a pituitary tumor resection. The physical examination revealed no acute distress. There was a negative bilateral Spurling's. Examination did not reveal any significant findings. The physician indicated she should undergo a magnetic resonance imaging (MRI) scan and utilize medications. It was recommended she begin prophylactic treatment with riboflavin twice a day. Given she has high blood pressure the physician detailed he would avoid caffeine-containing agents such as Fioricet or triptan's. Ubrelvy was recommended.

The patient was seen by Neurology for a follow-up. Since her last visit she stated she only had 4 migraines over 2 months. She stated that prior to her headaches the use of Ubrelvy helped. There were no other complaints. The examination did not reveal any significant abnormalities and it was recommended she continue with medication use.

A letter of medical necessity indicates the requested medication has been utilized for acute migraines. The physician detailed the patient is unable to utilize triptan medications due to high blood pressure.

The submitted documentation does indicate the patient was recommended to utilize the requested Ubrelvy due to the inability to utilize triptans or other medications such as Fioricet. However, there is no documentation indicating she cannot trial Nurtec. As noted by Up to Date both are calcitonin gene-related peptide (CGRP) antagonists and "there are positive randomized controlled trials for rimegepant (Nurtec) and ubrogepant (Ubrelvy) in acute migraine." Therefore, at this time the prior determination remains upheld.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for Ubrelvy is upheld. Medical necessity is not substantiated.