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

Physician 1:  The patient is a 62-year-old woman who has a history of chronic daily headache fueled by anxiety. Her medications include Fioricet, Prozac, Monopril, Toprol, Evista and possibly Maxalt. In January 2006 the patient received Botox therapy. She wishes to continue with the therapy and has requested coverage from her Health Plan. The Health Plan indicates the efficacy of Botox for the treatment of headaches has not been established in peer-reviewed literature.Botox is an accepted treatment for various types of headaches in patients who have failed standard therapies. It is usually appropriate for the patient to have tried and failed three to four prophylactic agents and various abortive medications prior to a trial of Botox. There is no clear evidence in this case of any trials of prophylactic medications. As such, Botox therapy is not medically warranted for this patient.Based upon the information set forth above, I have determined that the therapy at issue was/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 62-year-old female with a history of headaches, reported to be migraine. The patient suffers from stress and a sleep disorder. She has been treated with Monopril, Toprol, Evista, Ambien, Zetia, Fioricet, and possibly Maxalt. The patient received a trial of Botox with reported benefit. The Health Plan has denied coverage for Botox citing the investigational nature of the therapy.The long-term safety and efficacy of Botox has not been established. There is insufficient scientific data available for adequate evaluation of the use of Botox for headache relief. Furthermore, the submitted clinical evidence does not demonstrate the patient has exhausted conservative treatment. Therefore, I have determined that the therapy at issue was/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 62-year-old woman with chronic headaches. The submitted medical records indicate the patient uses between 10 and 20 tablets of Fioricet per month and experiences 10 to 12 days per month of headache. The records do not indicate specific subtypes of headaches (i.e., migraine versus tension type). The patient has received a course of Botox and reports that it has been beneficial. At issue is whether Botox therapy was/is likely to be more beneficial than any available standard therapy for the treatment of the patients condition. The records provided do not indicate the specific subtypes of headaches (i.e., migraine versus tension type). Furthermore, there is no documentation that this patient has been treated with a preventive medication such as a tricyclic antidepressant or any of the anticonvulsants that are effective in preventing headaches. There also remains the issue of likely rebound or analgesic-dependent headache based on the patients current use of Fioricet. Based upon the clinical information that has been provided, the patient has not failed standard preventive treatment of chronic 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.