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

Physician 1:  The patient is a 42-year-old female who is status post subarachnoid hemorrhage and surgical clipping and coil embolization with placement of a shunt. She has been experiencing daily headaches, which may be due to intracranial pressure variations, or medication rebound given the patients large daily doses of Fiorcet and Darvocet. She has failed Elavil, and is now on Topamax. Botox was recommended by the patients provider. The Health Plan has denied coverage for Botox on the basis that it is considered investigational. Review of the submitted clinical information indicates the patient has multifactorial headaches. Although Botox is accepted treatment for chronic migraine after the failure of three to four different classes of drugs, the patient does not fit this profile. She has a mixed migraine disorder and does not appear to have exhausted standard medical 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:  The patient is a 42-year-old woman with a complex medical history. She apparently suffered from migraine headaches, which were treated with a variety of medications. In October 2004 she suffered a subarachnoid hemorrhage, which was treated surgically (clipping and coil embolization). Subsequently she was noted to be afflicted with communicating hydrocephalus, requiring a shunt. A CT scan of the brain revealed ventriculomegaly. She has continued to experience severe headaches, relieved slightly with Topamax. Cervical radiculopathy has also been mentioned. Her neurologist has recommended treatment with Botox injections. The Health Plan has denied coverage for Botox on the basis that it is considered investigational.It is difficult to determine the underlying cause of this patients headaches (i.e., residual effects from her subarachnoid hemorrhage, shunt malfunction, common migraine and/or muscle tension type headaches). Given the uncertain etiology, there is not sufficient evidence that Botox injections are likely to relieve the patients headaches. Furthermore, the long-term efficacy of Botox for the treatment of headaches has not yet been established. 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 42-year-old woman with migraine type headaches following subarachnoid hemorrhage. The patient first came under the care of her neurologist in January 2006. She has a history of headaches dating back five years previous with aura and he documents a subarachnoid hemorrhage in October 2004 and reports that since then she has migraines twice per month and chronic daily headache. She was tried with Depakote and Elavil with no apparent improvement. Her neurologist noted possible medication overuse and started her on Topamax. The medical record indicates that the patient received at least 200mg of Topamax and achieved a reduction in the use of narcotic analgesics. A request has been made for authorization for Botox injections, which has been denied by the Health Plan.Botox has efficacy in treating both chronic daily headache and migraine. There is good evidence based on placebo-controlled, double-blinded studies. However, Botox is only indicated after standard medications have been exhausted. There remains an unanswered issue in this case as to whether analgesic rebound headache remained contributory and more responsible for the patients failure to respond to preventive treatment with medication. Furthermore, the submitted evidence does not document a trial of beta-blocker, a less anti-cholinergic tricyclic antidepressant or a SNRI type medication. The patient should exhaust standard available treatment prior to pursuing Botox treatment.Based upon the information set forth above, 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. Therefore, the Health Plans denial should be upheld.