Migraine Headaches denials in California external review

What the reviewers wrote

Where the denial was 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 patient’s 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for neurolysis of bilateral supraorbital and supratrochlear nerves. Findings: The physician reviewer found that Bink and colleagues note that the results from surgical treatment of neuralgia headaches are promising, reporting that in a systematic review, total elimination of symptoms varied between 8.3 and 83 percent. While this is a wide range, the authors noted that the number of patients with improvement of their symptoms was very high. The authors further noted that nerve decompression surgery is an effective way of treating headaches in a specific population of patients with neuralgia. Bajaj and colleagues report, “A total of 26 patients got benefitted with the local bupivacaine block, out of which 13 underwent surgery.

Where the denial was upheld

Physician 1The patient is a 44-year-old man with migraine headaches and comorbid depression, anxiety, and stress. He has requested authorization and coverage for Botox injections. The Health Plan has denied the patient’s request on the basis that Botox therapy is considered investigational. To date, few well-designed studies of Botox treatment for migraine headaches have been published. Thus, the long-term efficacy of Botox injections for treatment of the patient’s medical problems has not been established. Furthermore, it does not appear the patient has exhausted conservative treatment. Given the lack of long-term data on Botox therapy and the fact that the patient has not exhausted conservative treatment, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Crestor 5 mg once a day, Relpax 40 mg once a day, Diovan HCTZ 80-12.5 mg once a day, and Klonopin 0.5 mg once a day. In this case, the patient has medical problems including hyperlipidemia, hypertension, migraine headaches and chronic twitching of the eyelid. The medications including Crestor (rosuvastatin), Diovan HCTZ (valsartan/hydrochlorothiazide), Relpax (eletriptan) and Klonopin (clonazepam) are medically appropriate treatment for her medical conditions. However, the records provided for review do not support the medical necessity of the brand name formulations of these medications. Specifically, the documentation does not report that the patient has experienced any adverse reactions to the generic equivalents of these medications. When the U.S.

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