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

Physician 1The patient is a 44-year-old man with migraine headaches and comorbid depression, anxiety, and stress. He has requested authorization and coverage for Botox injections. The Health Plan has denied the patients request on the basis that Botox therapy is considered investigational. To date, few well-designed studies of Botox treatment for migraine headaches have been published. Thus, the long-term efficacy of Botox injections for treatment of the patients medical problems has not been established. Furthermore, it does not appear the patient has exhausted conservative treatment. Given the lack of long-term data on Botox therapy and the fact that the patient has not exhausted conservative treatment, 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 44-year-old man with a several year history of migraine headaches. The records show he has been tried on several triptans for abortive treatment as well as Depakote and Pamelor for prophylaxis. The patient has received a trial of Botox with some benefit. He has requested authorization for additional Botox therapy. The Health Plan has denied the patients request indicating Botox therapy is considered investigational for treatment of the patients medical condition.Although Botox has not yet been approved by the Food and Drug Administration for treatment of migraine headaches, there is growing support for use of Botox in patients who have failed multiple prophylactic medications. Based upon the submitted records, it appears the patient has had inadequate trials of prophylactic medications. Though the patient has failed Depakote and Pamelor for prophylaxis, there is no evidence he has exhausted other available medications. Thus, it does not appear standard prophylactic therapies have been exhausted. 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 3The patient is a 44-year-old man with a long-standing history of migraine headaches and chronic daily headaches. The patient has been treated with various medications such as Depakote ER, nortriptyline, Imitrex, Relpax, and Naprosyn. The frequency and intensity of the patients headaches have worsened recently secondary to stress, and the patient also has depression and sleep disorder. The patient underwent a trial of Botox injection in June 2004. Subsequently, the patients headaches have been of low intensity. The patient has also experienced side effects such as constipation, nausea, and abdominal cramps on his current medication regimen. The patient is seeking authorization and coverage for further Botox injections. The Health Plan has denied the patients request on the basis that the requested therapy is considered investigational for treatment of the patients headaches.Review of the submitted records indicates that despite conservative treatment the patient has been experiencing an increase in the frequency and intensity of his headaches. In addition, the patient has experienced untoward side effects on his current medication regimen. There is evidence the patient responded to a trial of Botox injections with a decrease in frequency and intensity of his headaches. With continued use of Botox it may be possible to wean the patient off his current medication regimen. As such, further use of Botox therapy is medically reasonable and appropriate. 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. The Health Plans denial should be overturned.