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

Physician 1: The patient is a 38-year-old female who has a history of migraine headaches that she experiences almost daily. She has been treated with frequent doses of sumatriptan. Her treating neurologist has suggested that she be treated with Zomig and Botox injections. She has been treated with Botox and wishes to be reimbursed for prior treatments. In addition, she is seeking coverage for future Botox treatments. The Health Plan has denied her requests.Review of the relevant medical literature demonstrates the efficacy of Botox has not been established. There is insufficient data that Botox provides long-term relief of headaches. Furthermore, the safety of chronic Botox administration has not yet been shown. Patients with frequent migraines experience the best results when treated prophylactically with medications such a Depakote, Topamax, or Atenolol. Given that the patient has not exhausted conservative treatment and due to the lack of long-term data on Botox therapy, I have determined that the therapy at issue was 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 patient is a 38-year-old woman with late onset of migraine headaches and has now developed a chronic daily headache syndrome in association with daily use of sumatriptan. She was seen by a headache specialist who treated her with low dose Botox. The patient is requesting reimbursement for the initial treatment as well as authorization for future Botox therapy.It appears this patient had triptan rebound headaches at the time she initially received Botox therapy. It is likely that triptan discontinuation alone would have been very beneficial. Additionally, there is no documentation indicating the patient underwent a trial of standard preventive therapy prior to her treatment with Botox. The patient is likely to experience significant improvement in her migraines with the appropriate use of usual preventive therapy and such therapy is likely to be more effective than Botox. Therefore, I have determined that the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 3: This patient is a 38-year-old female who has a history of migraine headaches and presented with medication overuse. The patients provider indicates preventive therapy was introduced but specific information has not been provided. Botox therapy was administered. The patient is requesting reimbursement for the Botox injections she has already received and authorization for future Botox injections.The Health Plans denial should be upheld. The submitted clinical records do not demonstrate that any medications for prevention were used prior to the Botox trial. Thus, it does not appear the patient has been tried on all available standard treatments for her headaches. If there is objective documented evidence the patient has tried and failed three to four prophylactic medications, her request for coverage for Botox therapy should be reconsidered. However, based on the information provided at this time, it has not been established that Botox was likely to be more effective for this patient than standard prophylactic medications. As set forth above, I have determined that the therapy at issue was 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.