Appeal type: Experimental/Investigational
Decision: Overturned

Physician 1: The patient is a 47-year-old female with chronic pain and temporomandibular joint dysfunction. She has requested authorization and coverage for Botox indicating it has reduced her need for Ultram by 50%. The patient continues to have moderate pain. The Health Plan has denied coverage for Botox therapy on the basis it is considered experimental for treatment of the patients medical condition.Review of the medical literature reveals little evidence to support the use of Botox for myofascial pain. The relevant literature mostly involves open label trials and case report series and is quite limited. Furthermore, the submitted clinical information does not provide sufficient detail regarding the patients attempts at standard therapy. It appears standard therapy, which may include surgery, is more likely to be effective for this patient than Botox therapy. 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 2: The patient is a 47-year-old female who has been diagnosed with temporomandibular joint (TMJ) disorder by two dentists. She has tried Botox in the past and has had relief of her pain. The patient has tried medications and splints without sustained relief. She has requested Botox therapy, which the Health Plan has denied as experimental for treatment of her myofascial pain disorder.TMJ disorder is a condition that results from overactivity of the temporomandibular muscles. The patient has apparently gained relief from previous use of Botox and has failed to respond to other forms of treatment. Botox appears to be safe, effective and approved for conditions that lead to muscular overactivity. For these reasons, 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. Therefore, the Health Plans denial should be overturned.Physician 3: The patient and her dental providers report a diagnosis of temporomandibular joint dysfunction with myofascial pain. She has had treatment with splints and pain medications that were of insufficient benefit. Treatment with Botox has allowed reduction of pain medications and has been with no reported serious side effects. The patient has requested authorization and coverage for additional Botox injections. The Health Plan has denied the request on the basis Botox is considered investigational in this clinical setting.Review of the submitted clinical information indicates Botox has been more effective for this patient than splints, trigger point injections, braces, acupuncture, physical therapy, oral medications with muscle relaxants, and pain medications. Given that the patient has failed a variety of standard pain control techniques and has experienced reasonable improvement since she began receiving Botox injections, further treatment with Botox is medically appropriate and should be authorized. 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.