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

Physician 1: The patient is a 32-year-old female with migraine worse with trauma. She has tried and failed numerous medications. She has tried Botox injections and has sustained pain relief for four years. The Health Plan has denied coverage for Botox injections on the basis Botox is considered investigational for treatment of migraine headaches.The medical literature is replete with studies suggesting that Botox is safe and efficacious for treatment of migraine headaches. In fact, Botox is commonly used for treatment of patients with recalcitrant migraines. Considering the severity and chronicity of this patients condition, and her prior response to use of Botox over the years, additional Botox injections are medically appropriate and are likely to be of greater benefit than conventional therapies. 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 2: The patient is a 32-year-old female who was involved in a motor vehicle accident in 2000. As the result of the accident she has noted worsening of her migraine headaches. She was subsequently diagnosed with post-traumatic stress disorder and was evaluated by a psychiatrist and treated by a chiropractor for cervical spine problems (whiplash). Since the summer of 2000 she has received Botox injections and has been prescribed Naprosyn, Topamax, and Zomig. She wishes to continue treatment with Botox. The Health Plan indicates Botox remains investigational for the treatment of migraine headaches. The use of Topamax, Naprosyn and chiropractic treatment are appropriate and should provide relief for this patients cervical spine problems. In addition, Zomig should provide acute relief of migraine headaches. Sessions and treatment with the patients psychiatrist should lead to improvement of the patients post-traumatic stress disorder. Standard therapies are likely to be of greater benefit for this patient than Botox injections. 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: The patient is a 32-year-old female with post chronic traumatic cervical myofascial pain associated with chronic post-traumatic migraine. She previously failed multiple acute therapies and muscle relaxants. The patient has been treated with Botox for several years with moderate relief of pain and return to function. She has also tried chiropractic, acupuncture, and trigger point injections. She is under the care of a headache specialist. The patient wishes to continue treatment with Botox injections. The Health Plan indicates the safety and efficacy of Botox for treatment of migraines has not been established.There is adequate evidence that Botox is useful in a subset of migraine patients. Thus, it is reasonable to attempt treatment with Botox in patients who have failed adequate trials of multiple standard preventive therapies. The submitted evidence demonstrates that the patient has tried most of the standard medicinal and alternative therapies for chronic pain and migraine without success. The patient has had moderate pain relief with Botox without any significant side effects for over four years. Botox therapy is medically warranted. 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.