Appeal type: Experimental/Investigational
Decision: Overturned

Physician 1: The patient is a 55-year-old female with transformed migraines with chronic daily headache. Her condition has been unresponsive to multiple preventive agents. In addition, she uses 2-3 Fiorinal per day, 1 Tylenol #3 per day and Imitrex 36 tablets a month. The patient has requested authorization and coverage for Botox for treatment of her headaches. The Health Plan has denied this request on the basis that Botox is considered investigational.There is adequate evidence that Botox is useful in a subset of migraine patients. Thus, it is reasonable to attempt treatment with Botox in patients who have failed adequate trials of multiple standard preventive therapies. The submitted evidence demonstrates that the patient has tried most of the standard medicinal and alternative therapies for chronic pain and migraine without success. 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 2: The patient is a 55-year-old female who experiences migraine, cervicogenic and muscle tension headaches. She has had migraine headaches since the age of 19. She wishes to be treated with Botox injections. The Health Plan has denied coverage for Botox citing a lack of established efficacy.Based upon the information provided, it appears the patient suffers from comorbid depression, muscle tension type headaches and cervicogenic headaches.  Patients such as this patient often benefit from antidepressant medication, Depakote (prophylactic migraine medication), and appropriate physiotherapy for cervicogenic headaches. To date, there is insufficient evidence Botox is safe and effective for treatment of the patients condition. 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 3: The patient is a 55-year-old female who has a long-standing history of migraines, managed by neurologists. Despite trials of multiple preventive agents she has continued to have frequent headaches. Most recently, she reportedly was taking lisinopril and Neurontin as preventives. She reports muscular tightness as a component of her headaches. She may be overusing analgesics at present, which can add to headaches or which may simply be in response to her headaches. The patient wishes to undergo a trial of Botox therapy. The Health Plan has denied coverage for Botox on the basis it is considered investigational.Standard therapies for headache prevention have been tried and failed in this case. The frequency and severity of the patients headaches necessitates preventive therapy. Botox has shown to be of benefit in patients who have refractory migraine, including those who have tried and failed conventional treatment or are in a medication overuse pattern. In addition, Botox has been beneficial for patients with muscular tightness. The patient should be approved for a trial of Botox therapy and if she has documented benefit, it should be continued at intervals equal to or greater than three months.As 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.