Chronic Daily Headache denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 47-year-old female who has high blood pressure, migraines, chronic daily headaches, TMJ, constant tinnitus, ear pain, vertigo, and carpel tunnel syndrome. She also has dizziness and facial pain due to a work-related injury that occurred in May 1989. She has failed several medications including Periactin, Imitrex, Vicodin, and others. The patient received Botox injections for two years. She has requested authorization for additional Botox therapy. The Health Plan has denied her request on the basis that the requested therapy is considered experimental for treatment of the patient’s medical condition.The patient has a complex history with significant chronic migraine headaches. She has reportedly tried many medications without benefit. She has used Botox for two years with relief. Botox is now in common use for the treatment of headache.

The patient’s parent has requested authorization and coverage for onabotulinumtoxinA (Botox) injections. Based on the available documentation and current medical literature, the requested Botox injections are medically necessary for treatment of this patient’s medical condition. The patient is already taking Prozac as an antidepressant, which is a relative contraindication to the addition of amitriptyline, a tricyclic antidepressant. Topiramate has the potential to worsen her depressive symptoms. Botox is a potent muscle relaxant, which has been found to have analgesic effects in patients with a variety of pain syndromes. Data from clinical trials have confirmed the efficacy, safety, and tolerability of Botox in the prophylactic treatment of chronic migraine in adults. The U.S. Food and Drug Administration approved Botox for the treatment of chronic migraine in 2010.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested medical services on an emergent or urgent basis. Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention on the dates of service in dispute. California law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient’s health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.

Physician 1The patient is a 23-year-old female who suffers from mixed headache syndrome and stress. The patient has been followed by a neurology clinic and was doing reasonably well with doses of Zomig but had untoward side effects. She was switched to Axert, which provided some relief. The notes indicate the patient has prolonged episodes of headaches. These appear to be muscle tension type headaches related to stress. She is also being treated with Zoloft. Because the patient is overweight and may have a mild thyroid deficiency, Depakote has not been tried. Calcium channel blockers have not been prescribed given the patient’s low blood pressure. The patient’s provider has recommended treatment with Botox.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving chronic daily headache, then check the rights and deadlines that apply to your plan.