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

Physician 1: The patient is a 51-year-old female with a history of migraine headaches, depression, bipolar problems, and anxiety. The patient has been treated with a large variety of medications aimed at her neurological and psychiatric problems, including prophylactics and medications used for acute incidents, with mixed success. The patient is seeking treatment with Botox. The Health Plan indicates Botox therapy for treatment of migraine headaches is considered investigational.Upon review of the submitted medical records, it appears the patient should first undergo treatment of her comorbid conditions such as depression and anxiety prior to pursuing pharmacological agents for the treatment of headaches. Frequently, the successful treatment of depression and anxiety renders the treatment of migraine or tension headaches easier and more successful. Patients with comorbid depression and anxiety often respond to relaxation techniques, thereby reducing the need, dosage, and frequency of pharmacological agents. Thus, there are more appropriate treatment modalities available for this patients condition than Botox.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 2: The patient is a 51-year-old female who has chronic migraines with possible rebound headaches. She has failed many medications. The patients condition has improved with a trial of Botox and therefore, she has requested authorization for additional injections.  The Health Plan has denied the request indicating the efficacy of Botox for treatment of migraine headaches has not been established.Review of the relevant medical literature shows growing support for use of Botox for migraines in cases where several prophylactic medications have been tried and failed. Thus, it is reasonable to propose treatment with Botox in patients who have failed adequate trials of multiple standard preventive medications. In fact, it has already been shown the patient has derived benefit from Botox injections. As such, Botox therapy is medically reasonable and appropriate and should be authorized.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.Physician 3: The patient is a 51-year-old female with a history of migraine headaches and bipolar disorder. She has been under the care of a neurologist and has tried and failed numerous medical therapies for treatment of her migraines. The submitted documentation indicates the patient has been maintained on medical therapy with Depakote, Imitrex, Relpax, Phenergan, as well as Xanax and Zoloft for depression and anxiety. Despite this regimen the patient continues with headaches requiring increased use of triptans and analgesics. The patients neurologist has diagnosed her with chronic migraines with probable triptan overuse and depression with bipolar disease. A trial of Botox therapy proved beneficial to her migraine condition. The Health Plan has denied coverage for Botox therapy on the basis it is considered investigational. The documentation provided clearly demonstrates Botox therapy has proved successful and effective for treatment of the patients chronic migraine condition. Review of the medical literature reveals Botox has an 80% success rate in reducing both the severity and frequency of migraine attacks and this efficacy can last from three to six months. The patient has tried conventional therapies and despite a significant medical regimen has continued headaches. Botox therapy has already been proven to be beneficial and additional injections are medically indicated. Accordingly, 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.