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

Physician 1: The patient is a 57-year-old woman with intractable migraines, muscle spasms, and cervicalgia. She has been tried on multiple medications, most recently, Dilaudid, methadone, Cymbalta, Keppra, Zomig and Mobic. A request has been made for authorization and coverage for Botox injections. The Health Plan indicates Botox has not been established as efficacious for treatment of the patients condition.The submitted information does not demonstrate that Botox therapy is likely to be of greater benefit for treatment of this patients headaches than standard therapy. The records provided do not demonstrate that the patient has attempted and failed available accepted and proven migraine therapies. There are other therapies available to this patient that have been proven to be more effective for treatment of intractable migraines than Botox therapy. 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 57-year-old woman with severe headache disorder characterized as atypical migraine with headaches, muscle spasms and neck pain. She is on daily narcotic treatment and has been tried on a variety of abortive and prophylactic therapies without significant help. The patient has requested authorization for Botox injections for treatment of her migraines. The Health Plan has denied this request on the basis that the efficacy of Botox has not been established in peer-reviewed literature.The medical literature is equivocal on the efficacy of Botox for migraine. The most recent article published in the Mayo Clinic proceedings is an amply powered study involving patients similar to this patient; the study failed to prove efficacy. The results produced no evidence that Botox therapy was better than placebo. Other studies are smaller and the data is conflicting. At this time Botox injections for the treatment of migraine headaches remain an unproven therapy. 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 57-year-old woman with a long history of atypical migraine headaches, muscle spasms and cervicalgia. She has been treated with methadone, Dilaudid, Zonegran, Zomig, Mobic, Cymbalta and Keppra. The patient wishes to undergo treatment with Botox injections. The Health Plan has denied authorization and coverage for Botox therapy the basis it is considered investigational for treatment of migraine headaches.The Health Plans denial should be upheld. The long-term safety and effectiveness of Botox injections has not been established in peer-reviewed literature. To date, there is inadequate evidence demonstrating that Botox is superior to standard therapies for the treatment of migraines. Upon review of the records provided it does not appear the patient has exhausted preventative medications. Further attempts at conservative therapy should be undertaken. 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.