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

Physician 1The patient is a 57-year-old woman with a history of severe debilitating migraine and muscle tension type headaches. It appears from the records provided that appropriate prophylactic and acute treatments have failed to provide relief for the patient. Botox injections appear to have been effective. The patient has requested authorization and coverage for additional Botox injections. The Health Plan has denied the patients request on the basis that Botox therapy is considered investigational for treatment of migraine headaches.Though Botox injections have not been approved by the Food and Drug Administration for the treatment of headaches, the medical literature is replete with studies suggesting that Botox is safe and efficacious. While it is true conventional medications are generally effective for the treatment of migraine headaches, some patients fail to respond to standard therapies. Considering the severity and chronicity of this patients condition, and her prior response to a trial of Botox, additional Botox injections are medically appropriate and are likely to be of greater benefit than conventional therapies. 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. The patients condition should be re-evaluated by her treating physician in six months to determine if Botox continues to be effective for treatment of the patients migraines.Physician 2The patient is a 57-year-old woman with a long-standing migraine history who has requested authorization and coverage for Botox injections. The submitted records indicate the patient has been tried on three preventative therapies, all of which have failed to provide any substantial relief. She has responded somewhat to Relpax, which is contraindicated with Biaxin, which her records indicate she is also taking. She continues to experience 5-12 migraines a month with moderate to severe disability. The Health Plan has denied authorization and coverage for Botox therapy on the basis it is considered investigational for treatment of headaches.Botox therapy is likely to be more beneficial for treatment of this patients migraines than standard medical therapy. The submitted records demonstrate the patient has previously responded well to Botox therapy. There is also sufficient literature to support Botox as a safe and potentially effective therapy for refractive patients. This patient has attempted conventional therapy without success. 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 3This patient is a 57-year-old woman with a 20-year history of migraine headaches. The submitted records indicate the patient has failed nortriptyline, Inderal, Depakote, and abortive therapy with Relpax, Imitrex, Maxalt, and Zomig nasal spray. The patient currently has headaches approximately seven times a month, which last from one to one-and-a-half days at a time. She was seen by a neurologist in April 2003 and received Botox injections, which resulted in significant relief from her headaches for three months. The patient has requested authorization and coverage for further Botox injections for treatment of her migraine headaches. The Health Plan has denied the patients request on the basis that Botox therapy is considered investigational for treatment of headache.Based on the patients history of severe migraine headaches and failure to respond to both a prophylactic and abortive medication regimen, Botox injections should be authorized. The patients trial of Botox therapy in April 2003 resulted in significant relief of her headaches for a three-month period and therefore, it is medically reasonable and appropriate to continue with Botox therapy. Given the patients history, it is not likely further attempts at conventional therapy will be effective. 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.