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

Physician 1: The patient is a 54-year-old female with a history of frequent disabling migraines. She also has a history of coronary artery disease and therefore, triptans are contraindicated. The patient has failed multiple prophylactic medications. She has requested authorization and coverage for Botox injections. The Health Plan has denied the request indicating the efficacy of Botox as a migraine therapy has not been established.Review of the medical literature reveals Botox has an 80% success rate in reducing both the severity and frequency of migraine attacks and this efficacy can last from three to six months. Use of Botox for treatment of migraine is becoming common among patients who have failed standard therapy. Botox is generally utilized after the patient fails at least three prophylactic drugs. Such is the case with this patient. Therefore, this patient meets the profile of patients who benefit from Botox therapy; a trial of Botox therapy is medically reasonable and appropriate. Based upon the information set forth above, 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 54-year-old woman with a diagnosis of intractable migraines as well as coronary artery disease. Headaches are described as severe. She has been tried on numerous abortive and prophylactic medications. The patient has also been tried on non-pharmacological treatment (i.e., biofeedback).  Other agents may be problematic given her cardiac history. The patients provider has recommended a trial of Botox. The Health Plan has denied coverage for Botox on the basis it is considered investigational in this clinical setting.Botox is a neurotoxin that causes muscle relaxation by blockade of acetylcholine release. It has been used in numerous neurological disorders, including pain syndromes. The patient has failed multiple drug trials using standard treatments, which represent agents considered generally efficacious by the American Academy of Neurologists. Given her continued headaches despite these medication trials, as well as biofeedback therapy, Botox is medically reasonable and offers low risk given her medical comorbidities. 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 54-year-old woman who suffers from intractable migraine headaches. In addition, the patient has significant cardiovascular disease that has required stenting of affected blood vessels. A number of medications (both abortive and preventive) and treatment modalities have been provided without success. Some medications commonly used for the treatment of migraine headaches (e.g., triptans and ergotrates) were either contraindicated because of the patients cardiovascular disease or caused adverse reactions. Consequently, it has been proposed the patient be treated with Botox injections. The Health Plan has denied authorization and coverage for Botox.The submitted information indicates the patient tried a number of medications, which apparently were ineffective. Though Botox therapy is not the standard of care for treatment of migraine and other headaches, the neurological literature reveals that the use of Botox for headaches is common and widespread in the practice of neurology as it is very effective and well tolerated. Furthermore, Botox is appropriate given the patients comorbidities since it is not likely to cause additional vascular problems. 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.