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

Physician 1: The patient is a 19-year-old female with chronic migraine and daily headaches with disabling headaches two to three days a week. She has failed four preventive agents and responds partially to triptans, but has side effects. Her headaches have become progressively worse over the past two years and she is using large amounts of Zofran to control nausea associated with migraine headaches. It does not appear she is experiencing medication overuse headaches. The patient wishes to receive Botox injections to control her headaches. The Health Plan has denied authorization for Botox therapy on the basis it is considered investigational for treatment of migraine headaches. There is adequate evidence that Botox is useful in a subset of migraine patients. Thus, it is reasonable to attempt treatment with Botox in patients who have failed adequate trials of multiple standard preventive therapies. The submitted evidence demonstrates that the patient has failed four preventive therapies. As such, Botox therapy is medically warranted. 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 2: The patient is a 19-year-old female with a history of chronic daily headaches and intractable migraine headaches. The patients neurologist has prescribed a large number of prophylactic and acute medications without success. It has been proposed that the patient receive Botox injections. The Health Plan has denied authorization for Botox on the basis that it considered investigational for treatment of migraine headaches. Though Botox injections have not been approved by the Food and Drug Administration for the treatment of headaches, the medical literature is replete with studies suggesting that Botox is safe and efficacious. 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. Considering the severity and chronicity of this patients condition, Botox injections are medically appropriate and are likely to be of greater benefit than conventional therapies. 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 19-year-old woman with a history of chronic intractable migraine headaches, which according to her neurologist, have worsened significantly over the past few years. The patient has failed multiple abortive and prophylactic medications including nortriptyline, Maxalt, Tylenol, Excedrin, Zonegran, Imitrex, Zomig, Relpax, Remeron, Topamax, Amerge, and Midrin. The patient has now requested authorization for Botox injections. The Health Plan had denied the patients request. Review of the clinical evidence provided demonstrates the patient has severe symptoms from her intractable migraine headaches and has failed to respond to numerous abortive and prophylactic medications in the past. However, it does not appear the patient has undergone a trial of beta-blockers or calcium channel blockers. If there are no contra-indications and if she has never been tried on beta-blockers or calcium channel blockers, then it is reasonable to attempt a trial with these medications before proceeding to 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 at this time. The Health Plans denial should be upheld at this time. However, if the patient fails a trial of beta-blockers and calcium channel blockers, her request for Botox injections should be reconsidered.