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

Physician 1The patient is a 38-year-old female with a number of medical issues including long- standing muscle tension headaches, degenerative cervical and lumbosacral spine disease, and psychiatric problems. Some of these problems appear to stem from an injury that the patient sustained as the result of a fall in August 2002. The patient has consulted several physicians and has attempted treatment with several different medications. She has received Botox injections that she reports have resulted in relief of her symptoms. She now wishes to continue with Botox injections. The Health Plan has denied authorization and coverage for Botox therapy on the basis that it is considered investigational.  To date, the long-term efficacy of Botox injections for treatment of the patients medical problems has not been established. Additionally, the possible adverse effects associated with long-term use of Botox have not been described and published. Furthermore, it does not appear that the patient has exhausted conservative treatment as there is no evidence of strict compliance to a comprehensive physiotherapy program. 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 2The patient is a 38-year-old female with a history of headaches and chronic neck pain, lumbar pain, and worsened headaches after a fall with head and neck injury in August 2002. She has been treated with pain management techniques and the use of daily Fiorinal, Lidoderm patches, Gabitril, Neurontin, and trigger point injections with minimal improvement. A variety of treatment modalities have been offered and refused including lumbar spinal steroids and C2 pulsed ablation therapy. The patient received Botox therapy, which provided relief for approximately three weeks. The patients provider indicated that five weeks post Botox therapy the patient continued to have substantial spasm in the neck muscles. A request has been made for additional Botox injections. The Health Plan has denied authorization and coverage for Botox therapy on the basis that it is considered investigational.The Health Plans denial should be upheld. Review of the current medical literature reveals that there is insufficient evidence that Botox is effective for tension type headaches or neck pain. In fact, the submitted records indicate the patient had a transient response to Botox therapy (approximately three weeks); clear physiologic response usually lasts three to five months. In addition, there is some likelihood that the patient is experiencing medication overuse headache (rebound headache) due to her daily use of Fiorinal. The patients headaches have some characteristics of migraine and therefore, consideration should be given to anti-migraine medication such as Depakote, Topamax, and Tricyclin antidepressants. In light of the clinical information provided, it appears that standard therapy is likely to provide greater benefit than additional Botox injections.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. Therefore, the Health Plans denial should be upheld.Physician 3The patient is a 38-year-old female with a history of severe neck muscle spasms causing neck pain after a slip and a fall accident in August 2002. The patient continues to experience neck and back pain resulting in headaches with associated nausea, vomiting, diarrhea, and chills. The patient has attempted treatment with trigger point injections, Neurontin, Gabitril, Codeine and Percocet without prolonged relief. The patient also received Botox therapy in February 2004, but again did not experience prolonged relief. The patient wishes to continue to receive Botox therapy. The Health Plan has denied authorization and coverage for Botox therapy on the basis that it is considered investigational.In cases of severe neck spasm and pain causing headaches there is no case-controlled literature supporting the use of Botox for treatment of headache associated with muscle tension. In addition, the submitted information shows that the patient did not receive prolonged pain relief from Botox therapy as her relief lasted only about three weeks. Furthermore, since all possible side effects from Botox injections are not known the use of frequent Botox injections when the duration of relief is relatively brief poses safety concerns. Standard treatment modalities should be utilized instead. 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.