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

Physician 1: The patient is a 35-year-old woman with migraine headaches who indicates she has responded to Botox therapy in the past. She is requesting authorization and coverage for further Botox injections. The records provided do not document the patients response to treatment with Botox. The Health Plan has denied coverage for Botox therapy on the basis it is considered investigational for treatment of migraine headaches.The Health Plans denial should be upheld. Although use of Botox for treatment of multiple migraine type headaches is becoming more common, it is generally only indicated after the failure of several prophylactic migraine medications. Based upon the information provided, it is not known what specific previous therapies and doses have been tried by the patient. Furthermore, there is insufficient documentation of the side effects and lack of efficacy with the patients previous therapies. Therefore, documented trials of prophylactic migraine medications are needed before treatment with Botox is considered. As such, 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 35-year-old female with chronic migraine and muscle tension headaches who has been treated with Botox and other medications aimed at treatment of her headaches. She has requested coverage for continued Botox injections. The Health Plan has denied the patients request indicating the efficacy of Botox for migraine headaches has not been established.Based upon the submitted clinical information, it does not appear the patient has had adequate trials of prophylactic medications. Standard medications (triptans and others), as well as alternative non-pharmacological treatment modalities (yoga, meditation, exercise, and dietary restrictions) are often useful, safe and effective in the treatment of migraines. The documentation provided does not demonstrate standard therapies have been exhausted by this 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 3: The patient is a 35-year-old woman who has experienced chronic migraine headaches at a frequency warranting preventive agents in addition to abortives. Prior treatment with first-line preventives including beta-blockers and antiepileptics was not successful. Botox was previously tried by the patient with some success. The patient wishes to continue treatment with Botox. The Health Plan has denied coverage for Botox injections.   Botox has been evaluated and has been found to be safe as well as beneficial as a preventive therapy for migraines. Patients who have tried and failed other preventives are often recalcitrant to additional oral medications and may be potentially helped with Botox. Documentation has been presented indicating this patient has failed other preventives and benefited from Botox. Therefore, additional Botox injections are medically reasonable and appropriate for ongoing management of the patients condition. Accordingly, 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.