Chronic Migraine 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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for occipital nerve block therapy. The management of chronic migraine focuses on prophylactic therapy and avoidance of acute headache medication overuse. Prophylactic interventions may include pharmacotherapy, behavioral therapy, physical therapy, lifestyle modification, neuromodulation, and avoidance of migraine triggers. Management often requires the simultaneous use of these different therapeutic modalities. Peripheral nerve blocks have been used for the acute and preventive treatment of a variety of primary headache disorders for decades. These procedures provide prompt pain relief for many patients with various headache types.

Where the denial was upheld

Physician 1: The patient is a 43-year-old female with chronic daily headache and a pituitary microadenoma (possible prolactinoma). She has been tried on Keppra, but the submitted records do not indicate she has tried any of the usual preventive medications. She has not had substantial response to usual acute medications such as triptans and butalbital compound. Her headaches are most consistent with chronic migraine. The patient was recently placed on Depakote, but the response to treatment is not documented. The patient’s provider has recommended a trial of Botox injections as preventive therapy. The Health Plan has denied coverage for Botox on the basis it is considered experimental for treatment of migraine headaches.The patient has chronic migraine.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for (1) occipital nerve blocks treatment, every four to six weeks, and (2) supra orbital nerve blocks treatment, every four to six weeks. Findings: The physician reviewer found that numerous systematic reviews support the efficacy of greater occipital nerve (GON) blocks versus placebo or no treatment for chronic migraine, there are very few studies comparing the effects of this treatment with other standard options for chronic migraines. Chowdhuri and colleagues report that the addition of GON blocks to topiramate was more beneficial than topiramate alone. However, there is little evidence for equal or greater effect of this procedure by itself compared to topiramate and other standard medications.

Compare the migraine diagnosis cohort with the named Ajovy, Emgality, Aimovig, gepant, and Botox record: migraine, CGRP drug and Botox denial evidence guide.

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 migraine, then check the rights and deadlines that apply to your plan.