Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1The patient is a 63-year-old woman with a reported history of migraines, which have responded to low-dose Botox. The patient indicates she experienced approximately four migraines per month prior to receiving Botox therapy. A request has been made for further treatment with Botox. The Health Plan has denied the patients request on the basis that the requested therapy is considered experimental.There is no indication in the submitted information that the patient has used any preventative therapy in the past. Furthermore, no information has been provided to indicate the patient has failed multiple acute therapies other than Imitrex. In light of this, standard preventive therapy is more likely to improve her condition 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 2The patient is a 63-year-old female with a history of severe migraine headaches for several years. The patient experiences three to four debilitating headaches per month. The headaches often last for days. Standard medical treatment for migraine headaches includes both oral and injectable medication (including Imitrex and other medications). The patients provider indicates standard treatment has not controlled either the severity or frequency of the patients headaches. However, Botox therapy has provided the patient with 3.5 months of relief from migraines with minimal side effects. The submitted information indicates the patient has received Botox therapy at four different times. The patient has requested authorization and coverage for additional Botox injections. The Health Plan has denied the patients request on the basis that the requested therapy is considered investigational.Based on the patients long-standing history of severe migraine headaches and lack of response to standard medical therapy, the patient should be able to continue treatment with Botox therapy. The patient indicates that she has experienced 3.5 months of pain relief after receiving Botox therapy. Continuation of Botox therapy will likely allow the patient to reduce her usage of other medications and increase her productivity. 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 3The patient is a 63-year-old female who has been experiencing migraine headaches for years. The patient indicates that Botox injections have provided relief from her migraines in the past. She has requested authorization and coverage for additional Botox injections. The Health Plan has denied her request on the basis that Botox is considered investigational for treatment of migraine headaches.The safety and long-term effects of Botox therapy for treatment of migraine headaches have not been documented in peer-reviewed studies. Migraine headaches can be treated prophylactically with medications such as Depakote or Timolol. Triptans should be taken for acute episodes. Although the submitted records indicate the patient failed to respond to Imitrex, there is no evidence that other triptans have been tried. Since it does not appear that the patient has exhausted standard treatment, use of Botox therapy is not indicated for treatment of the patients migraines.Based upon the information set forth above, 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.