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

Physician 1: The patient is a 46-year-old female with myofascial pain syndrome. The pain has been present for several years, affecting the left lower rhomboid mid-thoracic region. She has consulted a number of physicians. She has been seen and examined by a neurologist who made valuable suggestions for the treatment of her long-standing pain syndrome. The submitted evidence reflects the fact that the patient has been treated with a number of medications, including: Ultram, cyclobenzaprine, Flexeril, Elavil, Vioxx and Vicodin. She also has had the benefit of trigger point injections. None of these measures have provided the desired relief. X-rays and an MRI scan have revealed mild degenerative changes at T7-8, but no major abnormalities. The patient wishes to try Botox injections for treatment of her myofascial pain syndrome. The Health Plan has denied the request on the basis Botox is considered investigational for treatment of the patients condition.This patient does not meet the indications for treatment with Botox injections. There is no evidence in the peer-reviewed literature indicating Botox is efficacious for treatment of myofascial pain syndrome. Thus, there is insufficient evidence that Botox injections are likely to benefit the patient. The patient is likely to achieve superior results from standard therapies. 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 46-year-old female who has myofascial pain syndrome. She has tried multiple medications for her pain syndrome. She has also tried physical therapy, chiropractic, and trigger point injections, none of which provided sustained relief. The patient has requested authorization and coverage for Botox, which the Health Plan has denied on the basis Botox is experimental in this clinical setting.Review of the medical literature reveals little evidence to support the use of Botox for myofascial pain. The relevant literature mostly involves open label trials and case report series and is quite limited. Thus, there is currently insufficient data to support the use of Botox in this clinical setting. It appears standard therapy is more likely to be effective for this patient 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 3: The patient is a 46-year-old woman with a long history of chronic myofascial pain in the thoracic region. She is requesting approval for Botox therapy. The patient has been taking narcotics, muscle relaxants, and amitriptyline. She has been seen by multiple pain specialists and has tried chiropractic and trigger point injections with minimal improvement. The patient wishes to receive treatment with Botox injections. The Health Plan has denied authorization and coverage for Botox indicating is it considered experimental for treatment of the patients medical condition.The Health Plans denial should be upheld. There are no randomized, placebo-controlled trials demonstrating superior efficacy of Botox to current standard of care modalities for treatment of myofascial pain. As such, there is insufficient evidence that Botox injections are likely to result in a superior clinical outcome to standard 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.