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

Physician 1The patient is a 23-year-old female who suffers from mixed headache syndrome and stress. The patient has been followed by a neurology clinic and was doing reasonably well with doses of Zomig but had untoward side effects. She was switched to Axert, which provided some relief. The notes indicate the patient has prolonged episodes of headaches. These appear to be muscle tension type headaches related to stress. She is also being treated with Zoloft. Because the patient is overweight and may have a mild thyroid deficiency, Depakote has not been tried. Calcium channel blockers have not been prescribed given the patients low blood pressure. The patients provider has recommended treatment with Botox. The Health Plan has denied authorization for Botox indicating that it is considered experimental for treatment of migraine headaches.The long-term safety and efficacy of Botox has not been established. There is limited scientific data available for adequate evaluation of the use of Botox for headache relief. Patients who experience mixed headache patterns including migraine headaches due to stress often benefit from triptans in combination with Paxil or Indocin with Reglan for nausea, or small doses of timolol.  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 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 23-year-old college student who experiences one to two migraines per week. The patients migraines seem to have improved with triptan with underlying chronic daily headache. The only prophylactic medications that were tried were Elavil and Topamax. The most recent note from March 2004 indicates the patient is well controlled. The patient has requested authorization for Botox injections. The Health Plan has denied the patients request indicating that Botox is considered experimental for treatment of the patients medical condition.Review of the submitted records indicates the patient has not been tried on the more effective preventative therapies for headaches including beta-blockers, sodium valproate, and Neurontin. Thus, based upon the information provided, it does not appear the patient has exhausted conventional therapy. Therefore, at this time conventional therapy is likely to be more effective for treatment of the patients headaches than Botox therapy. 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 23-year-old college student who experiences one to two migraines per week. The patients migraines seem to have improved with triptan with underlying chronic daily headache. The only prophylactic medications that were tried were Elavil and Topamax. The most recent note from March 2004 indicates the patient is well controlled. The patient has requested authorization for Botox injections. The Health Plan has denied the patients request indicating that Botox is considered experimental for treatment of the patients medical condition.Review of the submitted records indicates the patient has not been tried on the more effective preventative therapies for headaches including beta-blockers, sodium valproate, and Neurontin. Thus, based upon the information provided, it does not appear the patient has exhausted conventional therapy. Therefore, at this time conventional therapy is likely to be more effective for treatment of the patients headaches than Botox therapy. 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.