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

Physician 1The patient is a 56-year-old male with severe depression, chronic daily headaches, and reported blepharospasm and cervical dystonia. The patient has been treated with Botox 100mg three times in the past with excellent results. He has been unresponsive to triptans and has used several anti-migraine preventatives in the past, which have not been successful in controlling his headaches.Review of the submitted records indicates the patient has been diagnosed with cervical dystonia and blepharospasm by his attending physician. The patient sought a second opinion from a neurologist who concurred with the use of Botox in this patient, specifically for chronic headache. Botox has been approved by the Food and Drug Administration as standard medical therapy for treatment of the patients medical condition. Therefore, 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 2The patient is a 56-year-old male with cervical dystonia, blepharospasm (Meige syndrome), headaches, and depression who has been treated with a variety of oral medications that have not been effective. He was evaluated by two neurologists who agree that periodic Botox injections would be effective and appropriate for this patients neurological condition. Previous Botox injections have provided relief for this patient. It has been suggested the patient receive Botox injections every three to four months. The Health Plan has determined Botox therapy is not medically necessary for treatment of the patients medical condition.Upon review of the information provided, it appears this patients headaches are due to cervical dystonia, which in turn leads to depression. Both the cervical dystonia and blepharospasm are well treated with Botox injections. The medication is approved for the treatment of dystonia and blepharospasm. Therefore, 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 3The patient is a 56-year-old male with a history of cervical dystonia, migraine headaches, and depression. The patients symptoms have been refractory to numerous therapies such as Imitrex, antihypertensives, and antiepileptic medications without relief of his headache pain. The patient received his first Botox injection in July 2003 with significant improvement in symptoms. He subsequently received two additional injections in January 2004 and April 2004, each providing relief for several months. The patients history is also complicated by depression that has required several hospitalizations for suicidal thoughts. The patient has requested authorization and coverage for further Botox injections. The Health Plan has denied his request on the basis that additional Botox therapy is not medically necessary.Based upon the patients long history of migraine headaches and cervical dystonia complicated by depression, the patient is likely to benefit from additional Botox injections. Prior Botox injections have resulted in significant relief with minimal side effects and continuation of the therapy will likely reduce the patients usage of other medications. Since the patients depression has required hospitalizations for suicidal thoughts in the past, the reduction of medication usage should be beneficial. Therefore, 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.