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

Physician 1: The patient is a 38-year old woman who sustained a cervical injury in 1994 as the result of a physical assault.  She has had a cervical fusion, left thoracic outlet decompression, and right scalenectomy since the incident.  She has chronic pain due to muscle spasms in the neck, shoulders and back.  More conservative treatments did not completely resolve her symptoms and she began Botox injections in 2003 and indicates that her symptoms have improved significantly.  The patient is requesting coverage for continued treatment with Botox injections.  The Health Plan considers the treatment investigational and has denied coverage.A review of the literature fails to confirm the safety and efficacy of Botox injections for pain due to thoracic outlet syndrome or cervical radiculopathy. With regard to this patient, it is not clear that Botox injections are the best treatment alternative. In particular, a consultation report from April 2003 noted that the patient did benefit from traction, heat and ice, and massage to an unstated degree.  It is not clear how helpful epidural injections or other medications have been for this patient. Thus, there is no distinct clinical or scientific evidence to demonstrate that Botox is likely to be of greater benefit to this patient than conservative treatment modalities. 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 2: The patient is a 38-year-old female with a history of a C5-6 fusion in 1997.  She suffers from chronic muscle spasms and pain.  The record demonstrates the failure of multiple remedies, both simple and more complex.  She has had three sessions of Botox to the cervical paraspinals and trapezius muscles that were reportedly helpful.  The patient has requested authorization for additional Botox injections, but the Health Plan has denied this request due to the investigational nature of the therapy.The patient has failed conservative therapy for her neck and shoulder spasms, and has clearly benefited from the three courses of Botox injections she received in the past.  Her clinical state is that of chronic muscle spasm with secondary pain.  It is probable that she will benefit from continued Botox therapy to her neck and shoulders.  The Botox injections should be authorized, as they are likely to give her more relief than the more conventional therapies already tried.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 38-year-old woman with chronic neck pain and chronic headaches who has failed multiple pharmacotherapies and interventional treatments.  She reports that her pain has been reduced with Botox injections and as a result she is able to work full-time and her overall quality of life has improved. The Health Plan has denied the providers request for additional Botox injections on the basis the therapy is experimental. This patient has a chronic pain syndrome since her cervical spinal and thoracic outlet surgeries and she has chronic headaches.  She has undergone extensive evaluation and has been treated with the usual medications including muscle relaxants, anti-inflammatories, tricyclic antidepressants, and narcotics with minimal relief.  Additionally, she has been treated with epidural blocks, TENS, and physical therapy without sustained relief. The previous Botox injections resulted in measurable improvement of her symptoms and allowed her to return to work. Given these results, continued treatment with Botox is medically reasonable and appropriate. For the reasons stated 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.