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

Physician 1: The patient is a 53-year-old female with constant intractable headaches described as myofascial/musculoskeletal or common migraine headaches without aura. The patient has been taking large quantities of Excedrin and Tylenol as well as other drugs. The patients neurologist recommended a trial of prophylactic medication. She wishes to be treated with Botox injections. The Health Plan has denied authorization and coverage for Botox on the basis it is considered investigational for treatment of the patients headaches.The long-term safety and efficacy of Botox has not been established. There is limited scientific data available for adequate evaluation of the use of Botox for headache relief. Additionally, the submitted records do not demonstrate the patient has undergone an adequate trial of prophylactic medications. Given that the patient has not exhausted conservative treatment and due to the lack of long-term data on Botox therapy, 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 2: The patient is a 53-year-old woman with chronic migraines with medication overuse headaches. Records from April 2005 indicate the patient was started on Topamax, but no information has been provided regarding the patients response to the medication. The patient reports receiving a single trial of Botox with some relief, but the records do not indicate the quality of relief or how long relief lasted. Neurologic workup was normal. The patient wishes to continue to receive Botox.  The Health Plan has denied coverage for Botox therapy on the basis it is considered investigational.The patients history and evaluation are consistent with migraines. The available records suggest the patient has been tried on Topamax, however, her response is unknown. There does not appear to have been an appropriate trial of preventive therapy in this case. Thus, there is not sufficient evidence to suggest Botox will be more effective than standard preventive therapies for the patients migraine headaches. 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 3: By history, this patient is a 53-year-old female who has chronic daily headache and underlying migraines with possible medication overuse headaches. She tried amitriptyline at a very low dose but the drug does not appear to have provided therapeutic benefit. Topamax was apparently tried but no information is provided regarding benefit or side-effects. It appears the patient received Botox for cosmetic purposes, which provided some headache relief. The dose and location of the Botox are not provided. A request has been made for authorization for additional Botox therapy. The Health Plan has denied this request. The patient has migraine and probable medication overuse related migraines, with chronic daily headaches. Use of Botox for refractory chronic daily headaches is supported by the literature, including use in patients who are experiencing medication overuse. The patient does not appear to have had adequate trials of preventive first-line agents per the submitted documentation. Continued attempts at preventive therapy are medically appropriate and indicated in this case. Based upon the information set forth above, 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.