Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1The patient is a 46-year-old female with a 25-year history of headaches. The etiology is unclear. She reports experiencing facial numbness. An MRI revealed a mild signal change in the pons. It appears the only prophylactic medications tried by the patient have been Inderal and Topamax. Abortive medications have included triptans and Fioricet. The patient has requested authorization and coverage for Botox therapy. The Health Plan has denied the request on the basis that Botox therapy is considered investigational for treatment of migraine headaches.The Health Plans denial should be upheld. Review of the medical literature suggests Botox therapy is sometimes effective for recurrent migraine headaches when other preventative medications have failed. The submitted records indicate the patient has only been tried on two preventative medications. As such, it does not appear that the patient has undergone a sufficient trial of prophylactic medication. Furthermore, the etiology of the patients headaches has not been clearly established. Thus, it is unclear whether Botox injections are likely to benefit the patient. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2The patient is a 46-year-old woman who has had migraine headaches for several years. The patient has been tried on several medications including Imitrex, Axert, Relpax, Maxalt, and propranolol. Her current medication regimen includes Topamax and Zomig nasal spray. The patients provider has recommended the patient receive Botox injections. The Health Plan has denied authorization and coverage for Botox therapy on the basis that it is considered investigational.Although Botox is not yet considered a standard therapy for the treatment of headache, there is a growing body of significant evidence demonstrating its efficacy in the treatment of headache. Many patients with migraines have benefited from Botox. Additionally, the patients records indicate that there is little likelihood that other available treatments will be beneficial. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3The patient is a 46-year-old female with a long-standing history of migraine headaches, which have significantly worsened over the last two years. Her current medications include Topamax and Zomig nasal spray, which she uses several times per week in order to abort the migraines. The patient has tried and failed other medications in the past such as Imitrex, Axert, Relpax, Maxalt, and propranolol. She has requested authorization for Botox injections. The Health Plan has denied her request indicating that Botox injections are considered investigational for treatment of migraine headaches.Review of the submitted records indicates the patients migraine episodes have recently become very severe and more frequent, requiring increased usage of Zomig nasal spray. The scientific literature does not yet have a large scale, double-blinded placebo-controlled trial to indicate superiority of Botox injections over placebo. However, there have been many patients among the numerous trials performed so far who have responded to Botox for periods ranging from three months to one year. Given these results and the failure of the patients attempts at standard therapy, Botox therapy is medically reasonable and should be authorized.Based upon the information set forth above, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.