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

Physician 1: The patient is a 46-year-old female with menstrual migraines who has been treated with Botox on four occasions over the past one-and-a-half years with apparent good results. However, the submitted records fail to document prior therapy and the patients response to therapy including her response to Botox. The Health Plan has denied authorization for continued Botox therapy. It is unclear from the records provided whether the patient has tried usual and customary therapy. It is also unclear what kind of response she has had to her ongoing low dose Botox therapy. If she has truly failed usual therapy including hormonal manipulation, daily NSAIDs, and daily triptans, Botox may be a reasonable option. However, the submitted records do not provide any information regarding the patients prior therapy. 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 2: This patient is a 46-year-old female with a history of menstrually associated migraine headaches. The patient states the headaches result in severe symptoms, which cause her to become bedridden for several days. The records submitted show the patient has received Botox injection several times in the past year. She has requested authorization for further treatment with Botox injections. The Health Plan has denied the request on the basis the requested therapy is considered investigational. The records submitted do not document any detail as to the patients baseline migraine severity, disability, the effect of prior preventative treatment efforts or the degree of benefit from the Botox injections that have been performed. As such, it cannot be determined if the patient has exhausted conservative treatment options. 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: This patient is a 46-year-old female with a history of menstrually associated migraine headaches with symptoms severe enough to cause her to become bedridden for several days. The patients provider indicates the patient has been treated with conventional and standard medicines. The patient has already received several Botox injections and has requested authorization and coverage for further injections. The Health Plan has denied the patients request on the basis that the requested therapy is considered investigational. The submitted documentation does not substantiate that the patient has failed to respond to conventional and standard therapies for treatment of her migraine headaches. As such, it has not been established that Botox is superior to standard treatment modalities for this patient. In the absence of clinical documentation regarding the patients prior treatment, there is no indication for Botox at this time. 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.