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

Physician 1: The patient is a female with chronic daily headache who is currently taking daily narcotics and Valium. The headache history is inadequate to determine the exact headache diagnosis. It appears the only preventive agent she has been on is Elavil. She has seen a neurologist in the past. Botox is being requested for a presumed diagnosis of tension-type headache. The Health Plan has denied coverage for Botox on the basis it is considered investigational.While the evidence for use of Botox for migraine is fair, the evidence that Botox is helpful for tension-type headache is poor. It is highly probable that this patient has medication overuse headache in light of daily narcotic and benzodiazepine use. It is likely this patient has chronic migraine, but the historical information is not adequate to determine a clear headache diagnosis. Based upon the information provided, it is more likely than not that this patient will respond to usual and customary therapy including detoxification and appropriate use of agents such as topiramate, valproate, and beta-blockers. 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 woman with chronic daily muscle tension-type headaches who has been followed by a pain management physician. The patients history indicates all diagnostic procedures have been negative and a number of medications have not provided relief. The patient has requested coverage for Botox therapy, which the Health Plan indicates is experimental.The literature concerning Botox injections for treatment of tension-type headaches shows the results are flawed. Additionally, it does not appear the patient has exhausted conservative treatment of her headaches. Non-pharmacological treatment modalities are more appropriate and likely to be more effective for treatment of the patients daily headaches. 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 female with a history of headaches since the age of 10. She apparently has daily headaches at this time. She has been seen by a neurologist and pain management physician and has been on preventive medications including Elavil and Paxil, as well as acute medications. The records provided indicate the patient has been diagnosed with chronic tension headache. The patient may well have transformed migraines. She has tried and failed prior preventives for headaches. A request has been made for authorization and coverage for Botox injections. The Health Plan has denied the request.The patient has disruptive headaches and is using daily pain medications. She has failed prior preventives and her diagnosis is refractory headaches. Botox treatment in this setting is likely to be more effective than continued attempts at standard treatment. Botox injections should be combined with an educational program to help wean the patient off of daily headache pain medications. Accordingly, 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.