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

Physician 1: The patient is a 54-year-old woman who suffered daily migraine headaches despite treatment with Amerge, Fioricet, and Maxalt.  She also received trigger point injections, which were somewhat effective, but did not provide long-term relief. The patient tried one unsuccessful Botox injection for treatment of her migraines.  She began Topamax in November of 2005. The patient is now seeking reimbursement for the Botox injection.  The Health Plan has denied coverage because the therapy is considered experimental/investigational for the treatment of migraines.The medical record provides no documentation of prior trials and failures of multiple prophylactic medications. Although Botox therapy may be appropriate when the patients migraines are resistant to standard prophylactic medications, there is no evidence the patient underwent such therapy. As such, she was not an appropriate candidate for Botox therapy at the time she received the injection. Therefore, I have determined that the therapy at issue was 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 54-year-old woman who is afflicted with migraine headaches and wishes to receive reimbursement for a Botox injection administered in August 2005, which did not relieve her symptoms. She is treated by a specialist and prior to the Botox, Amerge, Fioricet, and Maxalt were prescribed as appropriated medications for headache relief.  The patients headaches are a daily occurrence and possibly a combination of migraine and muscle tension headaches. The Health Plan has determined that Botox for the treatment of migraine headaches is an investigational therapy.Botox continues to be investigational for the treatment of migraine headaches, and it did not provide the hoped for relief for the patient. Other approaches should be attempted before such therapy is considered including prophylactic medications such as Depakote or Topamax. Zomig nasal spray and relaxation techniques may be helpful in relieving acute symptoms.  Therefore, I have determined that the therapy at issue was 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: The patient is a 54-year-old woman with daily headaches who requested a trial of Botox from her headache specialist.  The record indicates that he obliged her in August 2005 and the therapy was not helpful. The record does not show that the patient tried preventive medications in the past, although her provider did begin Topamax in November 2005. The Health Plan has denied the patients request for reimbursement for the Botox injection based upon their determination that Botox is investigational for the treatment of migraine headaches.The medical record includes a statement that Botox was given at the request of the patient. She apparently had good headache relief with Maxalt and Amerge.  The patient had chronic daily headaches, but preventive medications were not tried prior to the Botox. Treatment with preventive medications was indicated prior to consideration of Botox. Based upon the information gleaned from the record, I have determined that the therapy at issue was 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.