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

Physician 1The patient is a 38-year-old female with a long history of migraine headaches. The patients neurologist states the patient has tried a variety of triptans. The patient wishes to be treated with Botox injections provided by her neurologist. The Health Plan has denied authorization and coverage for Botox therapy indicating it is considered experimental for treatment of the patients migraine headaches.Though the literature is replete with reports on the effective use of Botox, it has not yet been approved by the Food and Drug Administration for treatment of migraine headaches. Recently, there has been evidence that Botox may not be safe. The information provided does not demonstrate the patient has exhausted conservative therapies. As such, continued attempts at conventional anti-migraine medications for either acute or prophylactic treatment should be attempted prior to pursuing 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 2The patient is a 38-year-old female with a long history of migraine headaches who reports her condition has improved with use of Botox injections. The records from her neurologist suggest the patient has not been on any of the FDA approved therapies for migraine, e.g., propranolol, topiramate, and sodium valproate. The records provided do not reveal the frequency of the patients migraines in the past or currently. The patient wishes to receive additional Botox injections. The Health Plan has denied authorization and coverage for Botox injections on the basis that the requested therapy is considered investigational for treatment of the patients migraine headaches.The patients history and evaluation are consistent with migraines. The available records suggest the patient has tried a variety of triptans; however, there is no mention of preventive therapy. There is not sufficient evidence to suggest Botox will be more effective than standard preventive therapies for migraine headaches. 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 3The patient is a 38-year-old female with a history of migraine headaches dating to her college years. Her headaches have been severe in nature and occur regularly. Multiple standard and conventional therapies have been tried without relief. The patient received her first course of Botox on October 2003, which was very effective in preventing her migraines. Since then she has had two more injections, one in February 2004 and another in August 2004. She now requests authorization and coverage for additional Botox injections. The Health Plan has denied the patients request indicating the requested therapy is considered investigational for treatment of migraines.Review of the submitted evidence indicates the patient has severe migraine headaches that do not respond to standard and conventional therapies. The patient received Botox injections in the past with good results. Botox has been very effective in preventing the patients migraines from occurring. Based upon these findings, the patient should be able to continue with Botox injections for treatment of her headaches. The patient does not appear to manifest adverse side effects from Botox injections. As such, additional Botox injections are medically reasonable and appropriate and likely to result in a superior outcome compared to conservative therapy. 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.