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

Physician 1This case concerns a 34-year-old male who has a long-standing history of migraine headaches. In addition, he experiences chronic pain related to carpel tunnel location of median nerve injury. His physician has indicated the patient has attempted multiple medications for pain management including Neurontin, Topamax, tricyclic antidepressants, beta-blockers, Maxalt and calcium channel blockers without relief. The patient reports he has received Botox injections in the past with some degree of headache relief. Therefore, he has requested authorization and coverage for Botox injections. The Health Plan has denied this request indicating the requested therapy is considered investigational for treatment of the patients migraine headaches.I would recommend the denial be overturned. The review of the medical documentation indicates the patient is a 34-year-old male with a history of chronic migraine headaches, diarrhea and sleep apnea. He began experiencing migraines in his 20s. He has tried various treatment modalities (see list above) with little relief. His present neurologist has determined that he has chronic migraines and myofascial features consistent with an underlying cervical dystonia process. He initially recommended continued therapy with Botox at an increased dose with a trial of another anticonvulsant, Keppra. The patient had significant GI intolerance to Keppra and has continued with daily headaches requiring pain control with Relpax with Oxy IR or Actiq as rescue pain medications. The patient did report Botox decreased the frequency of severe headaches by approximately 50%.The documentation has clearly demonstrated the patient has tried and failed standard therapy for control of his migraine headaches. He has been fully evaluated and despite treatment under the supervision of a neurologist has daily, often severe, migraine headaches. Furthermore, Botox therapy is no longer considered to be investigational or experimental in the treatment of migraine headache. Studies have indicated decreased frequency of headaches and decreased reliance on analgesic medications. In addition, it is felt the patient has cervical dystonia, a condition that is treated with Botox therapy. Given the patients failure to respond to standard therapies and his previous positive response to Botox, continuing Botox therapy is medically indicated and necessary for maximal control of his chronic pain condition.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 2This 34-year-old male has chronic pain syndrome with headache and myofascial pain syndrome. He has failed many medications and currently has a spinal cord stimulator, which does give him some relief. He has tried Botox injections for cervical dystonia, which has provided good relief. He is requesting further treatment of Botox therapy for his migraine headaches.Botox is now commonly used in the neurological community. For this patients condition Botox is considered standard of care if other appropriate medications have been tried and failed. This patient has attempted and failed appropriate medications. He has demonstrated relief with Botox injections. Because of the medications failures and relief with 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.Physician 3The patient is a 34-year-old male who has headaches (muscle tension type and migraine) and carpal tunnel syndrome (which was unsuccessfully treated surgically). The patient has been treated with numerous medications. This treatment has been unsuccessful and, because of the failure of these medications, Botox therapy was initiated. The patient has experienced relief with Botox and is now seeking authorization for further Botox therapy.Although Botox therapy has not yet been approved by the Food and Drug Administration for the treatment of headache, many patients derive benefit from Botox. This patient has attempted and failed standard (both acute and prophylactic) medications and has obtained relief with Botox. As such Botox has been more beneficial for this patient than any available standard therapy. Therefore, I have determined Botox 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.