Appeal type: Experimental/Investigational
Decision: Overturned

Physician 1: The patient is a 39-year-old female with a long-standing history of migraine headaches. The detailed medical records indicate the patients neurologist has treated the patient with a large variety of medications including Inderal, Celexa, oral contraceptives, Paxil, Feverfew, Topamax, and Botox injections along with several supplements. Botox has been the only therapy that has been successful. The patient has requested authorization and coverage for additional Botox injections. The Health Plan has denied the request on that basis that Botox is considered experimental for treatment of migraine headaches. Though Botox injections have not been approved by the Food and Drug Administration for the treatment of headaches, the medical literature is replete with studies suggesting that Botox is safe and efficacious. While it is true conventional medications are generally effective for the treatment of migraine headaches, some patients such as this patient fail to respond to standard therapies. Considering the severity and chronicity of this patients condition, and her prior response to a trial of Botox, additional Botox injections are medically appropriate and are likely to be of greater benefit than conventional therapies. 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 39-year-old female with a long history of migraine headaches that have increased in frequency and severity since 1997. The patients migraines have a premenstrual component and recently her migraines have also manifested neurological symptoms such as weakness, clumsiness, numbness, and disorientation. Numerous prophylactic medications have been tried over the years, including Inderal, Celexa, oral contraceptives, Paxil, Feverfew, and recently verapamil, none of which were effective. Naprosyn taken perimenstrually was only somewhat effective. The patient was unable to tolerate Topamax greater than 50mg a day because of the side effects. In January 2004, the patient received Botox injections, which provided almost three months of pain relief with no trips to the emergency room or her providers office. The patients physician believes the most effective regimen for the patient is a combination of Botox, low dose Topamax, and MigraHealth, as well as participation in a chronic pain workshop. The patient has requested authorization and coverage for further Botox injections. The Health Plan has denied the patients request on the basis that Botox therapy is considered investigational for treatment of the patients medical condition. The patient is a 39-year-old female with a long history of migraine headaches. Her condition has not responded to numerous prophylactic medication regimens but has responded to Botox injections. Since receiving Botox injections, the patient has reduced the frequency of her ER visits and doctors office visits. Though the patient does not appear to have been tried on a tricyclic anti-depressant or gabapentin, which are also first line agents for migraine prophylaxis, she is currently only able to tolerate a low dose of Topamax even though Topamax is effective. The side effects profile for tricyclics and gabapentin include somnolence and dizziness, which are similar to Topamax. Based on the patients history, her response to Botox injections, and her inability to tolerate or respond to other medication regimens, she should be continued on Botox injections as recommended by her physician. 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 39-year-old female who has a long history of migraine headaches. The patients provider indicates the patient has failed conservative therapies. The patient has received Botox injections in the past with reported relief. She has requested authorization and coverage for additional Botox injections. The Health Plan indicates Botox is considered experimental for treatment of migraine headaches. Botox is not the standard of care for treatment of migraine headaches. There is limited scientific data available for adequate evaluation of the use of Botox for headache relief. Review of the medical literature does not demonstrate the clinical efficacy of Botox has been established. Additional data is needed to determine the safety and efficacy of Botox for treatment of patients such as this patient. As such, further attempts at conservative therapy are likely to be of greater benefit to this patient than Botox injections. 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.