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

Physician 1The patient is a 44-year-old woman who has been experiencing left thoracic pain resulting from a motor vehicle accident that occurred some time ago. In spite of a long list of medications and procedures the patient has continued to experience pain in a left thoracic distribution. She has undergone nerve block and trigger point injections leading to temporary relief. The examinations by several physicians suggest that the origin of the patients pain is due to a disease, such as a ruptured or protruding thoracic disc. The patient indicates that Botox injections have been beneficial. She has requested authorization for further Botox therapy. The Health Plan has denied the patients request indicating the efficacy of Botox has not been established.It appears the patients pain is due to a combination of postural changes and muscle spasms. The patient has failed a variety of standard pain control techniques for treatment of her myofascial pain syndrome including epidural injections and many pain modulating medications. Many oral medications prescribed for the patient were ineffective and led to untoward side effects. Botox is indicated for the treatment of muscle spasms. Furthermore, there is documented evidence that the patient has experienced relief from Botox. Since the patient has failed conservative therapy, but has experienced relief from Botox injections, 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 2The patient is a 44-year-old woman with a history of left thoracic pain since September 2002 after being involved in a motor vehicle accident. She has been followed in a pain management clinic since January 2003. The patient has undergone numerous treatment modalities including selective nerve root blocks (T7-8, T9-11), which were minimally effective, physical therapy with use of TENS unit, which was not effective, and medications, such as Elavil and Neurontin, which were not significantly effective. She has also received trigger point injections, which provided significant relief for approximately one month, and Botox injections, which provided relief for several months. She also responded to intravenous lidocaine but was unable to tolerate mexiletine, an oral membrane stabilizer. The patient is also taking increasing doses of narcotics with resultant side effects. The patient has requested authorization for additional Botox injections. The Health Plan has denied her request on the basis that the efficacy of Botox therapy for treatment of the patients diagnosis has not been established.The submitted records indicate the patient has undergone numerous therapies and has experienced significant pain relief from trigger point injections, intravenous lidocaine, and Botox injections. However, the only therapy to provide long-lasting pain relief appears to be Botox injections. Thus, Botox therapy has proven to be more efficacious for this patient than standard therapies. Therefore, it is medically reasonable and appropriate to continue Botox therapy if the pain relief achieved continues to be in the range of approximately six months.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. The Health Plans denial should be overturned.Physician 3The patient is a 44-year-old woman who has a long history of thoracic pain. The patient has undergone nerve block and trigger point injections with temporary relief. The patient has also received Botox injections and reports that she experienced pain relief for a longer period of time than with other treatment modalities. She has requested authorization for additional Botox therapy. The Health Plan has denied the patients request on the basis that Botox is considered experimental for the patients diagnosis.Analysis and Findings:This patient has tried standard therapy with only short-term relief. There is sufficient scientific evidence to suggest that Botox has the potential to benefit this patients condition. Based upon the patients history of limited success with standard therapy and continued pain, Botox is an appropriate therapy for this patient. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.