Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 51-year-old woman with episodic dizzy spells, leg weakness, and fear of losing consciousness after cervical spine surgery. She finds Botox is helpful for these symptoms. The history provided by the patient does not make mention of migraine headaches, though the physicians report suggests the primary indication in this patient is a diagnosis of migraine. It is not clear from the information provided whether there has been subsequent worsening upon withdrawal of Botox. The Health Plan has denied coverage for Botox therapy on the basis it is considered investigational. There is no evidence that Botox is useful for spells of dizziness, leg weakness, and fear of losing consciousness. Additionally, the records provided do not support a diagnosis of migraines. Furthermore, the records provided do not document any prior treatment with conventional muscle relaxants, such as Baclofen or tizanidine, or any prior standard treatment for migraines. 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 51-year-old female with a history of migraines with associated muscle spasms. She has been treated with multiple pain medications for migraine and muscle spasms without success. The patient has been treated with Botox injections with substantial improvement and response with decreased spasms and migraines. The Health Plan has denied authorization and coverage for Botox therapy on the basis it is considered investigational for treatment of migraine headaches. The patient has a history of migraines and muscle spasm with pain. The clinical evidence documents that prior treatments were ineffective. Subsequent Botox injections have reportedly been well tolerated with excellent benefit. It is likely the patient will continue to tolerate and benefit from Botox injections. 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 51-year-old woman who experiences headaches and muscle spasms about the cervical spine following spine surgery for a herniated disc and bone spurs. She has been tried on conservative therapies in the past without success. The patient has achieved temporary relief from Botox injections and wishes to continue treatment with Botox. The Health Plan indicates Botox is considered investigational and therefore, has denied coverage for Botox.Review of the submitted clinical evidence indicates the patient has post-surgery pain and muscle spasms. These are frequently long lasting problems that require a well-designed treatment program designed by a physiotherapist. A self-directed and ongoing exercise program under the direction of a qualified physiotherapist is frequently the best treatment. The long-term safety and efficacy of Botox therapy has not been established. Botox will provide temporary relief at best and is not likely to be the most beneficial therapy for this patient. Post-surgical symptoms will recur without physiotherapy and an exercise program. 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.