Diagnosis: Migraine
Treatment: Ajovy 225 milligrams auto-injector (pre-service)

The insurer denied coverage for Ajovy 225 milligrams auto-injector (pre-service).
The denial is overturned.

The patient is diagnosed with migraine without aura and without status migrainous not intractable. The office visit noted the patient had subjective complaints of headaches. The prior treatments included Advil, rizatriptan, and Zofran, Migrelief, cyproheptadine, nortriptyline, and Ajovy. The patient had started Ajovy. The headache frequency improved drastically. The patient only had one migraine during the month and then stopped having headaches altogether. Oral contraceptive pills were ineffective for her headaches.

The Letter of Medical Necessity noted the patient had severe headaches that did not respond to multiple treatment options while Ajovy cured her headaches without side effects. The request was made for Ajovy and it was noted this would be for off label use and there was nothing that was on label for pediatric migraines.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

Szperka, C. L., & Gelfand, A. A. note "Anti-CGRP[calcitonin gene-related peptide] mAbs [monoclonal antibodies] have been shown to be effective for migraine prevention in adults and have not raised major safety issues, though long-term safety data are not yet available. Pediatric and adolescent trials of anti-CGRP mAbs should be designed to maximize the chances of determining efficacy in these age groups, and should focus on those who have not been successful with current multidisciplinary care. In the interim, the use of anti-CGRP mAbs for the treatment of headache disorders in children and adolescents may be considered in appropriate cases, but should be done with close follow-up and attention to patient characteristics such as age, pubertal state, and medical comorbidities."

The patient diagnosed with migraine without aura and without status migrainous not intractable had previously trialed Advil, rizatriptan, and Zofran, Migrelief, cyproheptadine, nortriptyline, and Ajovy. The Ajovy cured the patient's headaches without side effects. The literature supports that this type of medication appears to benefit a proportion of adolescents with chronic refractory headache disorders. The patient had a chronic refractory headache disorder. The medication was efficacious for this patient. It would not be in the patient's best interest to deny this medication. Ajovy 225 milligrams auto-injector (pre-service) is considered medically necessary for this patient.

Based on the above, the medical necessity for the medication Ajovy 225 milligrams auto-injector (pre-service) is substantiated. The insurer's denial is overturned.