Imitrex denials in California external review

What the reviewers wrote

Where the denial was overturned

A 41-year-old female enrollee has requested Imitrex (18 boxes per 90-day period) for treatment of her migraines. Findings: The physician reviewer found that the patient’s medical records suggest that she has chronic migraine, with a recent note documenting 16 severe headaches in a month. The American Academy of Neurology (AAN) guidelines based on well reviewed literature recommends prevention therapy with headaches of frequency more than four days per month that are disruptive, and acute abortive medications to reduce disability. The use of abortive medications more than an average of two to three days weekly can lead to medication overuse headache, and thus combined prevention treatment, and effective abortive use is advisable.

A 46-year-old male enrollee has requested an increased number of Imitrex kits per month for treatment of migraine headaches. Findings: The physician reviewer found that there is no evidence in the submitted medical records that the patient’s headache pattern has accelerated secondary to medication overuse (rebound) headache. Use of Imitrex at a frequency of 2 doses daily x 2 days weekly x 4 weeks monthly would result in acceptable use of 16 doses monthly. Therefore, 8 Imitrex kits (16 doses) monthly should be authorized for this patient. Consideration should also be given to specialty headache medicine consultation to evaluate novel approaches to prevention such as Botox therapy.

Where the denial was upheld

The patient is a 53-year-old man with a 20-year history of a trigeminal autonomic cephalgia most consistent with chronic cluster headache. The patient has nearly daily severe, incapacitating headaches with associated autonomic features that respond to Imitrex injections and partially to oral triptans. The patient’s neurologists have suggested reducing his use of triptans. He has tried and failed Topamax, Depakote, Neurontin, Verapamil, Lithium ES, Indocin, Lyrica, and Cymbalta. The submitted records do not include information about the dosing or duration of these medications.The patient is seeking coverage for reimbursement for his prior use of Imitrex as well as authorization for continued use of Imitrex at a frequency of two injections or two tablets per day.

The patient has had long-standing migraine headaches that respond to Imitrex. She is using 50mg tablets and indicates she needs more than one tablet per attack. Attacks remain frequent and may last days per the submitted records. Several prior preventatives have been used, apparently without much success. The patient has requested authorization and coverage for 27 Imitrex tablets per month. The Health Plan has determined the requested prescription is not medically necessary for treatment of the patient’s migraine headaches.The patient’s migraines are disabling and acute abortive therapy has been effective for this patient. However, she continues to have frequent headaches and does not appear to have been on any anti-convulsant category of prevention, such as Depakote, Topamax or Neurontin. Further preventive care is indicated with ongoing neurologic input.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Imitrex, then check the rights and deadlines that apply to your plan.