Appeal type: Experimental/Investigational
Decision: Overturned

Physician 1The patient is a 33-year-old woman with worsening headaches after a motor vehicle accident two years ago. She has tried and failed or was unable to tolerate, verapamil, Effexor, Topamax, Inderal, Pamelor, and Elavil. She was experiencing six to ten bad migraines a month. She underwent previous treatments with Botox with moderate to marked relief of pain. A request has been made for authorization and coverage for additional Botox injections. The Health Plan has denied the request on the basis the requested therapy is considered investigational for treatment of the patients medical condition.Review of the submitted records reveals the patient has intractable migraines. She has been under the care of multiple neurologists and has tried a wide variety of preventive therapy without success.  The patient has obtained benefit from Botox injections in the past. As such, she is a candidate for additional Botox therapy. 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 2This 33-year-old female patient has a long history of migraine headaches, which worsened after a motor vehicle accident in March 2002. She has tried numerous medications such as Ultram, Vioxx, Phenegan, Imitrex, Amerge, Frova, Zomig, Topamax, verapamil, amitriptyline, nortriptyline, and Inderal, all of which have either been ineffective or not well tolerated. The patient has also tried acupuncture without significant improvement. She has also received courses of Botox injections in the past. The submitted notes indicate the Botox injection received in April 2004 resulted in significant improvement in the patients migraine symptoms, which lasted approximately four months. The patient wishes to receive additional Botox injections. The Health Plan has denied the request on the basis that the requested therapy is considered investigational for treatment of migraine headaches.The records provided demonstrate the patient is unable to tolerate oral prophylactic medications, but does respond to Botox therapy with minimal side effects. As such, additional Botox injections are likely to reduce her medical utilization and increase her productivity. Given the patients poor response to a multitude of medications and the success of previous trials of Botox therapy, additional Botox injections are likely to result in a better clinical outcome than standard treatment. 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 33-year-old female with a history of frequent and disabling migraine headaches and neck pain after a motor vehicle accident in 2002. A long list of standard medications and therapies have been attempted to reduce the frequency and severity of the disabling attacks. The submitted documentation confirms that standard therapies have had inadequate benefit or resulted in excessive side effects. Treatment with Botox for the patients condition has on one or more occasions substantially improved her condition for a four-month period. No significant adverse effects were reported. A request has been made for further Botox injections. The Health Plan has denied the request on the basis that Botox injections are considered experimental for patients such as this patient.The patient has a disabling medical condition. Standard therapies have not been effective in managing her condition. 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 preventative therapies. The submitted clinical information indicates that Botox has been successful for this patient in the past. As such, additional Botox injections are medically reasonable and appropriate and should be authorized. 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.