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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Botox treatment for treatment of the enrollee who has a history of headaches. Findings:  The physician reviewer found that The documentation provided indicates that this patient presented for tension headache treatment. Tension headache is one of the most common headache types. The International Classification of Headache Disorders, 3rd edition (ICHD-3) states for the episodic form, it requires at least 10 episodes of headache lasting 30 minutes to seven days with at least two symptoms of bilateral location, pressing or tightening quality, mild or moderate intensity, not aggravated by physical activity, cannot have moderate or severe nausea nor vomiting, and no more than one of photophobia, phonophobia, or mild nausea. Tension headache classification can be broken down to the categories of infrequent (headache episodes less than one day a month), frequent (headache episodes 1 to 14 days per month), and chronic (headache 15 days or more a month). Therapy for tension type headaches ranges from drugs to nonpharmacological treatments with the goal of reducing frequency, severity, duration of attacks, improve function, and reduce disability. Best evidence for treatment of tension type headache is with tricyclic antidepressants, specifically amitriptyline. Other medications which have shown benefit are mirtazapine, venlafaxine, topiramate, and gabapentin. According to the documentation, the treatment requested is Botox for the treatment of tension headache.  However, the available medical evidence does not indicate that Botox is effective for tension type headaches with studies failing to show statistical significant differences between groups. The medical literature does not suggest that Botox is effective for tension headache. For these reasons, Botox treatments were not and are not likely to be more beneficial than the available standard therapy for treatment of this patients medical condition.  Final Result: The reviewers determined that the requested services were not and are 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. Credentials/Qualifications: Physician reviewer number one is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.