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

Physician 1:  The patient is a 47-year-old female who suffers from chronic migraine headaches.  She has been treated with a number of triptans which have only been partially effective and have produced side effects. She did however appear to have good results with Relpax as an abortive medication. The patient has also been prescribed Effexor and her letter suggests some depressive symptoms. The Health Plan has denied the patients request for authorization of Botox injections citing the experimental nature of the therapy.The underlying cause of this patients headaches is not entirely clear and it appears from the record there may be a comorbid depression. 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 2:  This patient is a 47-year-old female with chronic migraines who has failed multiple prophylactic and abortive medications. She has been experiencing headaches several times a week and Botox was recommended by the patients provider. The Health Plan has denied coverage for Botox on the basis that it is considered investigational. The submitted clinical records provide reasonable documentation of the patients previous failures with preventive medications. Botox is medically indicated when multiple standard medications have failed to provide relief from persistent migraine headaches. This therapy is commonly use by neurologists and is no longer considered an experimental or investigational treatment modality. As such, 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 3:  The patient is a 47-year-old woman with chronic migraine headaches that have apparently persisted on a two to four times per week basis. She has been treated with prophylactic agents such as Topamax, atenolol, Elavil, Zonegran, and Effexor but her headaches have continued. The patient has used triptans for interventional relief including Relpax, Maxalt and Imitrex; these products seemingly offered some temporary improvement. Her provider has requested authorization for treatment with Botox injections. The Health Plan has determined that Botox remains an unproven therapy for the treatment of migraine headaches and therefore has denied authorization and coverage.A review of the submitted medical records indicates the patient has been treated for adequate periods of time with accepted preventative therapies. Botox has been studied in well-designed, placebo-controlled, double-blind studies and is proven to be effective in reducing the frequency of migraine and chronic daily headaches. At this point I believe Botox is a widely accepted treatment in the practice of headache management. In this particular case, 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.