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

Physician 1: The patient is a 43-year-old female with chronic daily headache and a pituitary microadenoma (possible prolactinoma). She has been tried on Keppra, but the submitted records do not indicate she has tried any of the usual preventive medications. She has not had substantial response to usual acute medications such as triptans and butalbital compound. Her headaches are most consistent with chronic migraine. The patient was recently placed on Depakote, but the response to treatment is not documented. The patients provider has recommended a trial of Botox injections as preventive therapy. The Health Plan has denied coverage for Botox on the basis it is considered experimental for treatment of migraine headaches.The patient has chronic migraine. The records provided indicate she has only been on a single FDA approved preventive agent and according to the records, this was only recently started. There is no indication in the patients records of the response to this agent. The medical literature indicates Botox may be helpful for patients with chronic migraine who are refractory to standard preventive agents.  In the case of this patient, there is insufficient evidence the patient has been tried on the usual and customary treatment for migraine prevention such as beta-blockers, topiramate, and tricyclic antidepressants. As such, additional attempts with standard therapies are indicated before Botox is considered.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. The Health Plans denial should be upheld.Physician 2: The patient has a history of migraine and pituitary adenoma. Acute treatment medications are cited. She apparently has quite frequent migraines with near daily occurrences. Response to acute treatment medications has not been described in detail. It has been noted preventive medications were unsuccessful, but no description of the patients response or side-effects has been provided. The patients provider has recommended the patient undergo a trial of Botox injections. The Health Plan has denied coverage for Botox on the basis it is considered experimental for treatment of the patients medical condition.The patient has a history of migraine headaches that warrants prevention. Preventive treatment has been initiated. Response to preventive treatment may take one to two months to be evaluated. Failure of several preventive medications at adequate doses/duration may indicate refractory headache, which may respond to Botox therapy. This patient has not been documented to have refractory headaches. She should be tried on at least three preventive medications without adequate response before Botox is considered. 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 case involves a 43-year-old female with intractable daily migraine headaches. She wishes to be treated with Botox injections. She has been diagnosed with a pituitary adenoma (noted by MRI scan) that has apparently increased in size. The Health Plan has denied coverage for Botox indicating the therapy is investigational.Prior to exploring further treatment of her headaches, the patient should be evaluated for the most effective treatment of her pituitary adenoma. This condition is often successfully treated with gamma knife or other methods. Treatment of the patients pituitary adenoma is likely to reduce or eliminate her daily headaches. Given the specifics of this case, other treatment options are likely to be more effective than Botox therapy and are more clinically appropriate. 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.