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

Physician 1: The patient is a 40-year-old female who has chronic significant migraine. She has failed conventional therapy. She has benefited from low dose Botox therapy with improvement in her functional ability. She has requested reimbursement and continued authorization and coverage for Botox injections. The Health Plan has denied her request.Review of the relevant medical literature shows growing support for use of Botox for the treatment of migraines in cases where patients have failed standard therapies. There is sufficient evidence of the efficacy of Botox to support its use by patients such as this patient. In fact, it has already been shown that the patient has derived significant benefit from Botox injections. As such, Botox therapy is medically reasonable and appropriate and should be covered.Based upon the information set forth above, I have determined that the therapy at issue 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 2: This case involves a 40-year-old female who is being treated for migraine type headaches with Botox injections. The medical records reveal a history of migraine type headaches also described as a mixed headache disorder by her treating physician. The documentation of her prior treatment indicates she has tried Topamax, triptyline and Zanaflex without success. An MRI of the brain was performed in April 2003 and at that time her headaches were described as refractory over the past five months. The patient has requested reimbursement and prospective authorization and coverage for Botox. The Health Plan has denied her request on the basis that Botox remains experimental/investigational.Botox has been demonstrated to have efficacy in migraine and tension type headache in well-designed, placebo-controlled, double blinded studies. The use of Botox however, should be reserved for patients truly refractory to several preventive agents including tricyclic antidepressants, beta-blockers, anticonvulsants, calcium channel blockers and/or SNRI type of antidepressants. The medical record does not indicate whether there were issues of analgesic dependent headache or other issues that may relate to failure to respond to preventative medications. If satisfactory trials of these classes of medications are tried without success, then the patients request for Botox should be reconsidered. Based upon the information provided at this time, I have determined that the therapy at issue 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 40-year-old female with a history of recurrent headaches. She has tried multiple prophylactic and abortive medications as well as physical therapy without lasting benefit. A trial of Botox injections was successful. She has requested coverage for past and future use of Botox.Botox is becoming accepted treatment for migraine patients who fail multiple prophylactic medications. This patient fits the profile of an appropriate patient for Botox and has already demonstrated benefit from the therapy. Continuation of Botox is likely to of clinical benefit and therefore is medically reasonable and appropriate. Accordingly, I have determined that the therapy at issue 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.