Migraine denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 16-year-old female with a history of pelvic/groin pain. She has migratory pain in the lower abdominal quadrants and groin, right side greater than left. The pain is constant and always present, but can increase to as high as 7/10. She also complains of shoulder pain. She has a history of chronic bilateral frontal headaches, reported as migraines. She has undergone extensive workup in the past for the cause of her pain. Workup included multiple negative laboratory examinations, CT scans and abdominal pelvic ultrasounds. It also included extensive physical evaluations by multiple physicians. The patient has been evaluated and treated by a psychotherapist who feels no significant psychopathology is present. She has taken multiple medications including large doses of neuropathic pain medications such as Neurontin, trileptal, lidocaine and Ultram.

Physician 1This case concerns a 34-year-old male who has a long-standing history of migraine headaches. In addition, he experiences chronic pain related to carpel tunnel location of median nerve injury. His physician has indicated the patient has attempted multiple medications for pain management including Neurontin, Topamax, tricyclic antidepressants, beta-blockers, Maxalt and calcium channel blockers without relief. The patient reports he has received Botox injections in the past with some degree of headache relief. Therefore, he has requested authorization and coverage for Botox injections. The Health Plan has denied this request indicating the requested therapy is considered investigational for treatment of the patient’s migraine headaches.I would recommend the denial be overturned.

Where the denial was upheld

Physican 1: The patient is a 34-year-old female who suffers from headaches (migraine and most likely muscle tension headaches as well). She wishes to be reimbursed for Botox injections she began receiving in May 2004. The patient has been evaluated and treated by a neurologist who has continued to administer Botox injections. The Health Plan has denied coverage for the therapy on the basis it has not been shown in peer-reviewed literature to be more efficacious than standard migraine therapies. There are a variety of safe and approved medications for the treatment of headaches, either for prophylactic use or for occasional acute bouts of headaches. It is standard of care for such medications to be tried before consideration of Botox therapy. In the case of this patient, there is inadequate evidence her headaches were refractory to standard therapies.

Physician 1: The patient is a 42-year-old female who is status post subarachnoid hemorrhage and surgical clipping and coil embolization with placement of a shunt. She has been experiencing daily headaches, which may be due to intracranial pressure variations, or medication rebound given the patient’s large daily doses of Fiorcet and Darvocet. She has failed Elavil, and is now on Topamax. Botox was recommended by the patient’s provider. The Health Plan has denied coverage for Botox on the basis that it is considered investigational. Review of the submitted clinical information indicates the patient has multifactorial headaches. Although Botox is accepted treatment for chronic migraine after the failure of three to four different classes of drugs, the patient does not fit this profile. She has a mixed migraine disorder and does not appear to have exhausted standard medical therapy.

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