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

Physician 1The patient is a 54-year-old woman with a long-standing history of intractable migraine headaches. The patients provider reports the patient has tried numerous therapies without success including prophylaxis and abortive therapy. It appears the patients current regimen includes Zonegran and Relpax as needed. It has been recommended that the patient receive Botox injections.This patients headache pattern warrants preventative therapy and may indeed include elements of rebound headaches. The submitted evidence demonstrates the patient has tried various preventive oral medications, which were either ineffective or were associated with intolerable side effects. The medical literature shows the potential benefit of Botox in similarly affected patients with migraine, even those with medication overuse. The probability that this patient will have success with additional oral medications appears less than her chance of success with Botox therapy. 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 54-year-old female with long-standing frequent migraine headaches. The patient has failed more than four preventative therapies and uses frequent triptans. She has requested authorization and coverage for Botox injections. The Health Plan has denied the patients request on the basis that Botox injections are considered experimental for treatment of migraines.There is adequate evidence that Botox is useful in a subset of migraine patients. Thus, it is reasonable to attempt treatment with Botox in patients who have failed adequate trials of multiple standard preventative therapies. The submitted evidence demonstrates that the patient has failed more than four preventative therapies. As such, a trial of Botox therapy is warranted. 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. The patient should receive one course of Botox injections; if the trial results in at least a 50% improvement in the frequency and/or severity of the patients migraines then Botox therapy should be continued.Physician 3The patient is a 54-year-old female with a long-standing history of migraine headaches. The patients neurologist has indicated that the patient failed prophylactic medications such as Topamax, Neurontin, Depakote, and Zonegran. In addition, it has been noted the patient has failed abortive medications such as Imitrex, Frova, and Relpax. The patient is currently on a regimen of Zonegran 200mg a day and Relpax as needed (using approximately 12 doses per month). With the patients current medication regimen, she continues to have intractable migraines, which cause severe disability. The patient has requested authorization for Botox injections. The Health Plan indicates that Botox therapy is considered experimental for treatment of migraines.The patient has intractable migraines that have failed to respond to standard treatment. The current body of scientific evidence supports the use of Botox therapy as a last resort for patients with intractable or recalcitrant migraines. In the case of this patient, she either did not respond or was unable to tolerate any of the multiple medications she had been tried on. In light of the failure of standard therapy, Botox therapy is likely to be of greater benefit for this patient. As such, treatment with Botox injections is medically reasonable and appropriate.Based upon the information set forth above, 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.