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

Physician 1The patient is a 50-year-old male who has had daily migraine since February 2004. The patient has received some relief from occipital nerve blocks. He has also been taking Topamax. The patient has requested authorization and coverage for Botox injections. The Health Plan has denied the patients request on the basis that the requested therapy is considered investigational for treatment of the patients headaches.The Health Plans denial should be upheld. Although use of Botox for treatment of multiple migraine type headaches is becoming more common, it is generally only indicated after the failure of several prophylactic migraine medications. Based upon the information provided, it appears only one prophylactic medication has been tried by this patient. Therefore, additional trials of prophylactic migraine medications are indicated before treatment with Botox should be considered. As such, 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 2The patient is a 50-year-old male with headaches of acute onset six months ago. The patient also has vascular disease, sleep apnea, and work-related stress. The patient has been examined by a neurologist who indicated the patient is experiencing muscle tension headaches. The neurologist recommended a workup to determine the underlying cause of the patients headaches. The patient wishes to receive Botox injections for treatment of his headaches. The Health Plan indicates Botox therapy is considered investigational for treatment of tension headaches.In light of the unknown etiology of the patients headaches, a complete neurological workup is appropriate and necessary, particularly in cases such as this where headaches are of acute onset. It appears the patients headaches are best classified as muscle tension type and are possibly cervicogenic. Other possibilities such as vasculitis or giant cell arteritis should be ruled out. Meanwhile, Botox has not yet been approved by the Food and Drug Administration for treatment of various forms of headache. Treatment with standard therapy such as tizanidine is indicated until a complete workup is completed. In addition, physical therapy or relaxation techniques may be appropriate.Based upon the information set forth above, 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 3The patient is a 50-year-old man with a history of acute onset of headaches six months ago. The patient also has a history of lacunar stroke in February 2003 following arthroscopic shoulder surgery. The patient received occipital nerve blocks with some relief and has been taking Topamax. The patient also received Botox injections on 6/7/04, which apparently did not provide significant relief. The patient has requested authorization and coverage for Botox injections. The Health Plan has denied the patients request on the basis that the requested therapy is considered investigational for treatment of the patients medical condition.This patient with chronic daily headaches has been treated with Topamax and occipital nerve blocks. The patient noted some relief from occipital nerve blocks. It did not appear the patient experienced significant relief from a trial of Botox injections administered on 6/7/04. In addition, there is insufficient scientific evidence in peer-reviewed medical literature to support the efficacy of Botox injections for chronic daily headaches status post lacunar stroke. 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.