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

Physician 1: The patient is a 42-year-old female with over a 15-year history of chronic migraines. She experiences migraines more than 15 days per month. The patients headaches have been unresponsive to betablockers, several tricyclic antidepressants, Depakote, Topamax, and Zonegran. The patient has used Botox for over three years with moderate improvement. She is currently experiencing disabling headaches in the absence of Botox. The Health Plan has denied authorization and coverage for Botox on the basis it is considered investigational for treatment of migraine headaches.The patient has a history of significant chronic migraine headaches. She has tried and failed more than six preventive agents and has tried essentially all standard therapies. She has used Botox for several years with documented improvement. Botox is generally used in patients who have failed multiple prophylactic medications. In this case, it has been established that Botox is effective for this patient. As such, further use of Botox is medically appropriate and indicated for this patient. 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 2: The patient is a 42-year-old female with a 15-year history of migraine headaches, occurring two to three times per week. The patient has been treated with Botox injections, which have provided some degree of relief. The patient was prescribed Topamax for prophylaxis but complained of memory loss. She was also tried on Elavil, which resulted in weight gain. Neurontin was ineffective. The records also suggest the patient has comorbid depression. The patient wishes to continue treatment with Botox. The Health Plan has denied coverage for Botox indicating it has not been shown to be efficacious in peer-reviewed literature.Upon review of the submitted medical records, it does not appear the patient has exhausted preventive medications such as Timolol. Standard medications, as well as alternative non-pharmacological treatment modalities (yoga, meditation, exercise, and dietary restrictions), are often useful, safe and effective in the treatment of migraines. The long-term safety of Botox has not been adequately evaluated at this time. 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 female with a very long history of disabling migraines. She has tried and failed multiple standard measures. When her headaches are severe, triptan medications are not always successful, leading to increased disability. She has been treated in clinical trial as well as open-label with Botox. The patients treating physician has reported decreased headache frequency and severity as well as better response to triptans. The patient indicates she has increased headaches when Botox wears off three to four months following treatment.This patient has chronic migraine and chronic daily headache. She reports having more than 15 headache days per month. Standard preventives from several classes have either failed or were associated with excessive side effects. The patient has been tried on Botox in the past and it has been of consistent benefit as a preventive therapy without extensive side effects. Furthermore, there is increasing support in the medical literature for use of Botox in refractory patients. 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.