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

Physician 1This case involves a 42-year-old female with severe refractory migraine headaches almost on a daily basis. Treatment has consisted of medications (Ultram, Anaprox, Imitrex, and Indocin), and non-pharmacological treatment including acupuncture, yoga, chiropractic manipulation, and psychiatry. The patient has received Botox injections in the past for cosmetic reasons, which provided her with relief. She has requested additional Botox therapy for treatment of her migraines. The Health Plan has denied this request indicating that Botox is considered investigational for treatment of the patients medical condition.The long-term safety and efficacy of Botox have not been established. There is limited scientific data available for adequate evaluation of the use of Botox for headache relief. Patients such as this patient should be treated with medications aimed at prophylaxis such as beta-blockers, calcium channel blockers, and certain anti-epileptic drugs. These medications are generally effective and well tolerated. Given that the patient has not exhausted conservative treatment and in light of the lack of long-term data on Botox therapy, 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 2The patient is a 42-year-old female with a history of severe, refractory migraine headaches who has requested authorization and coverage for Botox injections. She has tried and failed multiple medications including Ultram, Anaprox, Imitrex, and Indocin. In addition, she failed treatment modalities such as acupuncture and chiropractic manipulations. The patient received several Botox injections and appears to have experienced pain relief lasting approximately three months. She indicates that when her pain returns her emergency room visits increase in frequency. The Health Plan has denied coverage for Botox therapy on the basis it is considered investigational for treatment of the patients medical condition.Based on the patients lack of response to medication and non-invasive treatments for migraine headaches, and her positive response to Botox injections, continued injections should be authorized. The patient does not appear to have experienced significant adverse effects from Botox therapy. Furthermore, she has been able to reduce medical utilization (i.e., ER visits) and increase her functions. Given these findings, continued Botox therapy is medically reasonable and appropriate. 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. Therefore, the Health Plans denial should be overturned.Physician 3This case involves a 42-year-old woman with severe, refractory migraine headaches. The patient states she experiences headaches on almost a daily basis. The patient has failed treatment with several medications including Ultram, Anaprox, Imitrex, and Indocin. She has also received Botox injections in the past with good results. She has requested additional Botox therapy for treatment of her migraines. The Health Plan has denied this request indicating that Botox is considered investigational for treatment of the patients medical condition.There is adequate evidence that Botox is useful in a subset of migraine patients. Thus, it is reasonable to attempt treatment with Botox in patients who have failed adequate trials of multiple standard therapies. The submitted evidence demonstrates that the patient has failed several medications as well as chiropractic manipulation and acupuncture. Furthermore, the patient has previously obtained pain relief with Botox injections. As such, additional Botox therapy is warranted. 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.