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

Physician 1: The patient is a 54-year-old female with a 15-year history of episodic migraines occurring three to four times per month. Her migraines have been poorly responsive to triptans. The patient received two courses of Botox injections for which she has requested reimbursement. In addition, the patient has requested authorization for future Botox injections.The patient reports she had virtually complete resolution of migraines for six months following Botox therapy. The submitted clinical records do not document a trial of preventive therapy other than Botox.The Health Plan has denied coverage for Botox therapy on the basis it is considered investigational for the treatment of migraine headaches.The submitted records provide no objective evidence the patient has been tried on usual preventive therapy such has beta-blockers, tricyclic anti-depressants, Topamax or Depakote. The patient has episodic migraines rather than chronic migraines (greater than 15 headache days/months). Recent large, double-blinded, randomized, multi-center clinical trials confirm that Botox is no more effective than placebo in this patient population.The patient is likely to experience significant improvement in her migraines with the appropriate use of usual preventive therapy and such therapy is likely to be more effective than Botox. It appears a consultation with a neurologist or headache specialist would be beneficial for ongoing migraine management. Based upon the information set forth above, I have determined that the therapy at issue was 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 54-year-old female with a 15-year history of migraine headaches. She wishes to be reimbursed for two courses of Botox injections, which provided good relief of her migraine headaches and were well tolerated. She states that triptans did not provide relief of her migraines. The patient has also requested coverage for continued Botox injections. The Health Plan has denied coverage for Botox on the basis that its efficacy in the treatment of migraines has not been established.Review of the relevant medical literature demonstrates the efficacy of Botox has not been established. There is insufficient data that Botox provides long-term relief of headaches. Furthermore, the safety of chronic Botox administration has not yet been established. Patients with frequent migraines experience the best results when treated prophylactically with well-tolerated medications such a Depakote and other medications such as Topamax. Given that the patient has not exhausted conservative treatment and due to the lack of long-term data on Botox therapy, I have determined that the therapy at issue was 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: This patient is a 54-year-old woman who has had migraine headaches for over 15 years. She experiences several migraines per month. She is unable to tolerate triptans. The patient reports decreased headache frequency with Botox therapy. There is no documentation of trials of prophylactic migraine medications in the records provided. The Health Plan has denied coverage for past and future Botox injections on the basis that Botox has not been established as effective for the treatment of migraines.Although the patient indicates she has failed triptans, there is no evidence of a trial of prophylactic medications in the information provided. Thus, it does not appear the patient has been tried on all available standard treatments for her headaches. If there is objective documented evidence the patient has tried and failed three to four prophylactic medications, her request for coverage for Botox therapy should be reconsidered. However, based on the information provided at this time, it has not been established that Botox is likely to be more effective for this patient than standard prophylactic medications. As set forth above, I have determined that the therapy at issue was 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.