Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Migraines
Treatment: Pharmacy/Prescription Drugs (Botox)
The health plan denied the requested prescription drug (Botox). The health plan's determination is overturned.

This is a female who is being followed for migraines. She was previously treated with Aimovig, and when she discontinued breast-feeding was recommended to initiate Botox. She receives Botox, and Aimovig concurrently. She had a headache about 14 weeks after her last Botox injection when Botox was stopped. The two medications were then continued together. 
The reason for denial on the prior review as per a communication was that Botox is not required for the direct treatment or management of the patient's medical condition, if not provided the medical condition could get worse. Letters of medical necessity from the patient's provider indicates that Botox reduced her migraines and noted that at that time it was being provided in combination with Aimovig. An office note from her provider indicated that the patient was off Aimovig and requested reinitiating of Botox. 
A communication from the neurologist indicates that the patient was using Aimovig and Botox, then came off Aimovig within the previous two months and was no longer taking Aimovig. Botox was requested.
On a later date, it was noted that she had received Botox, which resulted in improvement in her headaches. She had previously utilized trigger point injections, tricyclic antidepressants and Topiramate. She is currently taking Topiramate. It was noted that she had not been on Aimovig for over a year and it was indicated that Botox was denied because the patient was on Aimovig. Her neurological examination was normal at that time.
On a later date, the patient was seen by her provider with intractable migraine headaches. It was noted that Nurtec had worked well. Aimovig alone did not reduce headaches, Aimovig was stopped, and Botox was being continued. Her headaches had a decrease of over 15 headache days per month to "a few headaches per month" with Botox. She had previously failed tricyclic antidepressants and remained on Topiramate at that time. She has not been on Aimovig in almost a year per the documentation.

The health plan's determination is overturned, in whole.

Botox is medically necessary for this patient. This is a patient with a diagnosis of chronic migraine, who has been treated with Botox. Botox reduced the frequency of her migraines from 15 or more days per month to "a few headaches per month." Botox is not being provided in combination with Aimovig or any other CGRP agent. The patient had an inadequate response to Aimovig alone. The patient is still taking Topiramate. She had a poor response on tricyclic antidepressants. As the patient had a trial and failure of two medications of different oral migraine prophylactic medications from different classes and has had a prior response to Botox, and is no longer taking Aimovig, the use of Botox is medically necessary based on current peer-reviewed medical literature. Her migraines initially occurred 15 or more days per month, Botox was prescribed by a neurologist, and she has had previous trials and failures of an anticonvulsant and tricyclic antidepressants.