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

Physician 1This patient is a 48-year-old woman with a long history of cervical pain. The patient has had multiple cervical surgeries and has not responded to conservative treatment. Apparently, the patient has been treated with Botox in the past and wishes to continue to receive Botox injections. The Health Plan has denied authorization for Botox therapy indicating it is considered investigational for treatment of the patients diagnosis.Review of current medical literature fails to confirm the efficacy of Botox in the treatment of the patients medical condition. Botox therapy for chronic cervical pain, myofascial pain, and failed neck syndrome has unproven efficacy in case-controlled, randomized, peer-reviewed literature. Thus, there is no scientific evidence to demonstrate that Botox is likely to be of greater benefit to this patient than conservative therapies. 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 2The patient is a 48-year-old woman with an extensive history of cervical pain. She has intractable pain and has undergone four cervical surgeries without relief. Additionally, the patient has failed multiple orthopedic procedures, invasive pain procedures, and medications. The patient indicates she has responded to Botox therapy in the past. She has requested authorization for additional Botox injections. The Health Plan has denied the patients request indicating that Botox therapy is considered experimental for treatment of the patients cervical pain.The patient has failed a variety of standard pain control techniques for treatment of her dystonic pain including epidural injections, pain modulating medications, and multiple invasive procedures. The patient indicates that she has experienced reasonable improvement since she began receiving Botox injections. However, the submitted medical records do not document the duration of the patients response to Botox therapy. Since the patient has failed conservative therapy, but has experienced relief from Botox injections, 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. Another course of Botox therapy should be authorized. If there is documented evidence from the patients provider that this course of Botox therapy is effective for a prolonged period of time (i.e., six months), then Botox therapy should continue to be authorized. Physician 3The patient is a 48-year-old woman who has requested authorization and coverage for Botox therapy. The Health Plan has denied this request indicating that the requested therapy is considered experimental for treatment of the patients pain. The patient has a long history of cervical pain. She is status post three cervical fusions at four levels (C4, C4-5, C5-6, C6-7) and her neck pain has been exacerbated by a motor vehicle accident, which also resulted in her complaint of severe headaches. In April 2003, the patient underwent posterior C5-C6 lateral mass-fusion and instrumentation using iliac crest bone graft. In July 2003, the patient received a series of four trigger point injections at weekly intervals. She then received Botox injections in September 2003. The patient reports good response but the duration of response is unclear based upon the submitted clinical records. The patient has a long-standing history of cervical pain and is status post multiple cervical fusions. The patient has experienced headaches/exacerbations of cervical pain due to a motor vehicle accident. Since the patient has failed standard therapy, if Botox therapy allows the patient to become functional for at least six months, then the patient should continue to receive Botox injections if there are no adverse side effects. Given the patients lack of response to standard therapies and her reported good response to an initial course of Botox, 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. The patient should receive another course of Botox therapy. Upon documentation from the patients provider of improvement in the patients symptoms, additional courses of Botox therapy should be authorized.