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

Physician 1: The patient is a 56-year-old female with frequent migraines, which have not responded to several preventive medications, but have responded to treatment with Botox. The records indicate she has had a fair response to triptans, and is at risk for rebound. She has moderate disability related to her migraines. The Health Plan has denied coverage for Botox on the basis it is considered investigational for treatment of migraine headaches. This patient has moderate to severe migraines. By report she has responded to Botox injections. Based upon the records provided, the patient has not been tried on FDA approved migraine preventive agents such as Depakote, Topamax, and Inderal. I find that it is more likely than not that standard migraine preventive therapy will be as or more effective than Botox injections. 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: This case involves a 56-year-old woman with intractable, familial migraine headaches and possible comorbid restless leg syndrome and depression. She is being treated with a large variety of oral medications. The patients neurologist has treated her with Botox injections that have provided her with relief of her migraines. The Health Plan has denied coverage for the requested therapy on the basis it is considered investigational for treatment of the patients medical condition. While it is true conventional medications are generally effective for the treatment of migraine headaches, some patients such as this patient fail to respond to standard therapies. Botox tends to be effective and well tolerated in the treatment of some refractory cases. Considering the severity and chronicity of this patients condition, and her prior response to a trial of Botox, additional Botox injections are medically appropriate and are likely to be of greater benefit than conventional therapies. Botox injections should be administered every three months. Therefore, 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 3: The patient is a 56-year-old female with a long-standing history of migraine headaches. She has tried and failed numerous medical treatment regimens including Imitrex, Zomig, Relpax, Neurontin, Zoloft, Elavil, Naprosyn, Cafergot, and Vicodin. She was evaluated by a headache specialist and given a trial of Botox injection therapy in June 2004. She had an excellent response to Botox therapy with more than a two-month absence from severe incapacitating headaches. The headache specialist has recommended continuation of treatment with Botox. The Health Plan has denied coverage for Botox on the basis it is considered investigational in this clinical setting. The submitted documentation clearly demonstrates the patient had a significant and sustained response to Botox therapy. She has failed standard therapy for migraine treatment and prior to Botox therapy was using 36 Vicodin per month for pain relief. Since cessation of Botox therapy she has had significant absence from work due to intractable migraine headaches. There is growing support for use of Botox for treatment of intractable migraine headaches. Botox does decrease migraine frequency, abortive medication usage, and associated vomiting. Additionally, it has been demonstrated to reduce the severity of migraine episodes and decrease the use of rescue medications. The patient has had a documented significant and sustained response to previous Botox therapy. As such, Botox therapy is medically appropriate and indicated at this time for this patient who has tried and failed numerous therapies. Based upon the information set forth above, I have determined the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.