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

Physician 1: The patient is a 42-year-old male who experienced an injury while fighting a fire resulting in shoulder/periscapular pain that has persisted over 1.5 years. He has attempted conventional therapeutics including physical therapy, oral medications, home exercises and trigger injections without relief. Imaging of the spine showed no clinically relevant abnormalities. EMG showed no radiculopathy or plexopathy. A request has been made for authorization and coverage for Botox injections. The Health Plan has denied this request on the basis that Botox is considered investigational in this clinical setting.The patient has a myofascial pain syndrome status post trauma and surgery. The medical literature regarding Botox and pain relief is substantial when looking at dystonia as the underlying diagnosis. Based on these results the use of Botox has been extended to treatment of myofascial pain. While the literature regarding myofascial pain is not as robust, it has been established that Botox shows benefit in individual patients. Furthermore, the safety of Botox is well established.Treatment paradigms are evolving and have not been fully studied and published. Given the failure of standard therapeutics to provide this patient with relief, a trial of Botox therapy is medically reasonable and appropriate. If there is no documented benefit with Botox, it should not be continued.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 2: The patient is a 42-year-old male who sustained a work injury in 2004 and has persistent left shoulder pain. He has attempted conservative measures such as physical therapy, trigger point injections, and medications without sustained relief. The patient is requesting Botox therapy for treatment of ulnar neuropathy. A request has been made for authorization and coverage for Botox injections. The Health Plan has denied this request on the basis that Botox is considered investigational in this clinical setting.The use of Botox for treatment of ulnar neuropathy remains unproven without established efficacy. There is no clinical evidence indicating that this treatment is a reasonable preventive modality for this patient or within the standard of care. The patient is likely to experience better results with continued attempts at standard therapies. 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.Physician 3: The patient is a 42-year-old male enrollee with left sided shoulder pain and left ulnar neuropathy. He is requesting authorization for Botox injections for treatment of his pain. The Health Plan has denied this request on the basis that Botox is considered investigational in this clinical setting.The Health Plans denial should be upheld. There is no scientific evidence in the peer-reviewed literature supporting the efficacy of Botox injections in the treatment of ulnar neuropathy. No significant trials have been performed and there is only anecdotal information regarding the possible efficacy of the therapy. Without further study and research, it is not possible to predict whether the proposed therapy will benefit this patient. 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.