Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 40-year-old female with migraine headaches that began in October 2003. She has been treated with a variety of medications including Excedrin, Tylenol, Flexeril, Imitrex and Topamax. These medications failed to provide long-term relief. She reports experiencing some relief with Botox therapy. The Health Plan has denied coverage for Botox on the basis it is investigational for the treatment of migraine headaches.The long-term safety and efficacy of Botox therapy has not yet been established. Excellent results have been achieved using Zomig nose drops for acute headache episodes and Depakote (a mood stabilizer) or channel blockers such as atenolol as prophylactic treatment for chronic, recurrent migraines. The patient is likely to experience greater benefit from standard therapies than from Botox, which remains unproven for this indication. 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 40-year-old woman with a history of chronic daily headaches for two years with underlying migraine. She has had some relief of acute headaches with Imitrex injections. She has failed Topamax. The patient also suffers from depression and probable fibromyalgia. She has responded to Botox therapy on two previous occasions with moderate, but rather short-lived improvement. The Health Plan indicates Botox is considered investigational for the treatment of migraines and therefore has denied coverage for the therapy.This patient has chronic daily headache and probable transformed migraine-type headaches. She is under the care of a dentist who specializes in pain management. She has failed at least one documented preventive therapy. Additionally, she had only a moderate response to Imitrex. The submitted records indicate the patient has responded to Botox therapy. As such, continuation of Botox is medically reasonable and appropriate as long as the patient continues to experience a 50% reduction in headache frequency.  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 3: The patient is a 40-year-old female who has had headaches since October 2003. She has jaw pain and is under the care of a pain management dentist. Botox injections have been transiently helpful on two occasions in the past. Conventional treatment is described consisting of a trial of Topamax, Imitrex and Effexor/ Compazine. It does not appear that the patient is under the regular care of a headache neurologist. There is no indication of treatment with other agents such as valproate, propranolol or tricyclics. MRI studies and neurologic exam are normal.A request has been made for authorization and coverage for additional Botox injections. The Health Plan has denied this request on the basis that Botox remains an unproven therapy for the treatment of migraines.This patient has not had the benefit of appropriate potentially beneficial therapies of a conventional nature. Furthermore, the fact that she responded to prior Botox injections does not indicate specific benefit from Botox injections. Multiple clinical trials have demonstrated high rates of placebo response, and conflicting data continues to be published on the effectiveness of Botox therapy. The efficacy of Botox remains unproven and conventional therapies as prescribed by headache specialists would supersede its use. Accordingly, 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.