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

Physican 1: The patient is a 34-year-old female who suffers from headaches (migraine and most likely muscle tension headaches as well). She wishes to be reimbursed for Botox injections she began receiving in May 2004. The patient has been evaluated and treated by a neurologist who has continued to administer Botox injections. The Health Plan has denied coverage for the therapy on the basis it has not been shown in peer-reviewed literature to be more efficacious than standard migraine therapies. There are a variety of safe and approved medications for the treatment of headaches, either for prophylactic use or for occasional acute bouts of headaches. It is standard of care for such medications to be tried before consideration of Botox therapy. In the case of this patient, there is inadequate evidence her headaches were refractory to standard therapies. Accordingly, I have determined that the therapy at issue was 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.Physian 2: The patient is a 34-year-old female with episodic migraines who was initially seen in 2002 with 10-12 headache days a month. She was felt to have some elements of medication overuse headaches. She was started on Gabitril and a variety of triptans. She had marked improvement with birth control pills, but was still treated with Botox (first injections were in May 2004). The only preventive agent documented in the records is Topamax. It does not appear the patient has been on beta-blockers, valproate or tricyclics. The records indicate she is doing well. A request has been made for reimbursement for the Botox injections the patient received. The Health Plan has denied this request on the basis that the therapy at issue is considered investigational.This patient appears to be responsive to hormonal manipulation. Botox was used early in her course of treatment, prior to trials of standard therapies. It appears from the records provided that the patient has episodic migraine. Recently published phase II studies showed no difference with Botox as compared to placebo in this patient population.It is likely that standard preventive therapy would be as or more effective than Botox in this patient population. As such, I have determined that the therapy at issue was 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 34-year-old woman who has had a history of frequent headaches with migraine. Records from 2002 indicate the patient was on no preventives. At that time she was to participate in a Botox chronic headache study. She may well have had medication overuse headaches at that time and a withdrawal regimen was started with Axert and Gabitril. Duration of treatment was not specified; the next progress note dated nearly two years later (March 2004) also showed no preventive medications. A treatment note from May 2004 does not note medications but describes the patient as better. In May 2004 the patient had her first charted Botox injection for headache. In January 2005 she was started on Topamax and it was noted she had been on Provigil and Effexor. Subsequent notes state the patient was doing well on that regimen.The patient has requested reimbursement for the Botox injections she has received. The Health Plan has denied this request.The patient has a long history of migraine headaches. Based on the medications that have been prescribed, she apparently has comorbid depression and anxiety. She was noted to be doing well in the period of 2002 through 2004 but began Botox injections in May 2004. She has had several Botox treatments since that time.There is little indication the patient had been on preventives prior to her first documented Botox injection. In this clinical setting it is appropriate for patients to be tried on a standard preventive regimen prior to undergoing treatment with Botox. Therefore, I have determined that the therapy at issue was 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.