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

Physician 1The patient is a 47-year-old female who has high blood pressure, migraines, chronic daily headaches, TMJ, constant tinnitus, ear pain, vertigo, and carpel tunnel syndrome. She also has dizziness and facial pain due to a work-related injury that occurred in May 1989. She has failed several medications including Periactin, Imitrex, Vicodin, and others. The patient received Botox injections for two years. She has requested authorization for additional Botox therapy. The Health Plan has denied her request on the basis that the requested therapy is considered experimental for treatment of the patients medical condition.The patient has a complex history with significant chronic migraine headaches. She has reportedly tried many medications without benefit. She has used Botox for two years with relief. Botox is now in common use for the treatment of headache. It is generally used in patients who have failed multiple prophylactic medications. In this case, it has been established that Botox is effective for this patient. As such, further use of Botox is medically appropriate and indicated for this patient. 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 2The patient is a 47-year-old female who experiences intractable migraine headaches and chronic daily headaches, temporomandibular joint problems, tinnitus, popping sounds, ear pain, and has a past history of vertigo. The patient has received Botox injections in the past with reported relief. She has requested authorization and coverage for further Botox injections. The Health Plan has denied her request indicating that Botox therapy is considered experimental for treatment of her condition.The submitted information indicates the patient tried a number of medications, which apparently were ineffective. Though Botox therapy is not the standard of care for treatment of migraine and other headaches, the neurological literature reveals that the use of Botox for headaches is very common and widespread in the practice of neurology as it is very effective and well tolerated. In fact, prior use of Botox by this patient was successful without intolerable side effects. Further treatment with Botox is likely to result in continued benefit. 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 3The patient is a 47-year-old female with a long-standing history of intractable migraine headaches and chronic daily headaches. The patient also has symptoms of dizziness, vertigo, ringing in ears, temporomandibular joint problems, loss of hearing, fibromyalgia, joint stiffness, muscle spasms, and carpel tunnel syndrome. The patient has been treated with Periactin, Vicodin, NSAIDs, Imitrex, and trigger point injections without significant relief. The patient received Botox injections from November 2002 through November 2003 with significant pain relief of three months noted following each injection.A request has been made for additional Botox injections. The Health Plan has denied this request on the basis that Botox therapy is considered experimental for treatment of the patients medical condition.The efficacy of Botox therapy for treatment of migraine headaches has not been established in peer-reviewed literature due to the small sample size in studies showing a positive response to Botox injections. However, in the case of this patient, there is documented evidence that she responded positively to Botox injections for one year of therapy. As such, continuation of Botox injections is medically appropriate and is likely to be of greater benefit than standard treatment modalities.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.