Muscle Spasm: when insurers say no, reviewers often say yes

Where the denial was overturned

Physician 1: The patient is a 38-year old woman who sustained a cervical injury in 1994 as the result of a physical assault. She has had a cervical fusion, left thoracic outlet decompression, and right scalenectomy since the incident. She has chronic pain due to muscle spasms in the neck, shoulders and back. More conservative treatments did not completely resolve her symptoms and she began Botox injections in 2003 and indicates that her symptoms have improved significantly. The patient is requesting coverage for continued treatment with Botox injections. The Health Plan considers the treatment investigational and has denied coverage.A review of the literature fails to confirm the safety and efficacy of Botox injections for pain due to thoracic outlet syndrome or cervical radiculopathy. With regard to this patient, it is not clear that Botox injections are the best treatment alternative.

A 40-year-old female has requested botulinum toxin injections for treatment of muscle spasms. Findings: Two physician reviewers found that botulinum toxin is an accepted treatment for cervical dystonia and various types of headaches in patients who have failed standard therapies. In this instance, the patient has severe muscle spasms refractory to medications and non-pharmacological interventions. She did however respond to a trial of Myobloc. As is the case with migraines, since standard interventions were not helpful, a trial of botulinum toxin was clinically reasonable and was shown to be effective for this patient. Continued treatment with Myobloc is indicated as long as a positive response is documented.

Where the denial was upheld

Physician 1: The patient is a 51-year-old woman with episodic dizzy spells, leg weakness, and fear of losing consciousness after cervical spine surgery. She finds Botox is helpful for these symptoms. The history provided by the patient does not make mention of migraine headaches, though the physician’s report suggests the primary indication in this patient is a diagnosis of migraine. It is not clear from the information provided whether there has been subsequent worsening upon withdrawal of Botox. The Health Plan has denied coverage for Botox therapy on the basis it is considered investigational. There is no evidence that Botox is useful for spells of dizziness, leg weakness, and fear of losing consciousness. Additionally, the records provided do not support a diagnosis of migraines.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for use of a power scooter. In this case, the patient has decreased mobility with a history of low back pain and muscle spasm, as well as knee pain and osteoarthritis with prior knee arthroplasty requiring revision surgery. However, the records do not sufficiently document that the patient requires a power scooter for mobility and performing daily activities of living in the home or community setting. The patient requires standby assistance for performing transfers and ambulating with a cane. The medical records do not support that the patient cannot use a cane or walker for assistance with ambulation or propel a manual wheelchair for mobility.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for muscle spasm was denied, the published record says the denial is worth fighting.