Appeal type: Experimental/Investigational
Decision: Overturned

Physician 1: This patient is a 49-year-old female with a history of refractory migraine and myofascial pain dating back to her multiple motor vehicle accidents in 1987. She states that the muscle pain can trigger her migraines. The patient achieves relief of her migraines with Relpax, but is requiring treatment often (1-2 times per week). Prior preventive treatments have failed including non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants, though no specific mention is made of any trials of migraine preventives. Physical medicine measures have apparently not relieved the patients myofascial pain either. The Health Plan has denied the patients request for authorization of Botox injections due to their determination that the therapy is experimental/investigational in nature.The patients myofascial pain is refractory, and standard pain management approaches have failed. Botox therapy is reasonably likely to decrease the myofascial pain in the patients shoulder, neck and back. The patient may also benefit from a trial of standard migraine preventives. Based upon the evidence provided, a trial of Botox therapy is medically appropriate and indicated for treatment of the patients myofascial pain. 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 49-year-old female who has a long history of migraine and chronic right shoulder, neck and back myofascial pain. These complaints started with the several motor vehicle accidents she sustained sometime in or around 1987. The patient has tried several physical medicine treatments and medications for relief of her pain to no avail. She is requesting Botox therapy in an effort to achieve long-term resolution of symptoms. The Health Plan considers the requested therapy experimental/investigational and has therefore denied authorization and coverage.This patient has maximized conservative care without any lasting change in her myofacial pain symptoms. The use of Botox therapy in this context has gained acceptance in the literature and is a medically reasonable option when conservative treatment modalities fail. Given the documented failure of standard measures in this case, Botox therapy is appropriate and should be authorized. Accordingly, 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: This patient is a 49-year-old female with chronic neck and shoulder pain of presumed myofascial etiology. Treatment with interventional therapies and medications has not been successes in eliminating her pain.  She is requesting approval for Botox injections.  The Health Plan has denied her request because the therapy is considered experimental/ investigational.The Health Plans denial should be upheld. There are no randomized, placebo-controlled trials demonstrating superior efficacy of Botox to current standard of care modalities for treatment of myofascial pain. Botox therapy is not FDA approved for use in chronic myofascial pain and is not the generally accepted treatment approach.  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.