Botox Injections 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.

Physician 1The patient is a 44-year-old woman who has been experiencing left thoracic pain resulting from a motor vehicle accident that occurred some time ago. In spite of a long list of medications and procedures the patient has continued to experience pain in a left thoracic distribution. She has undergone nerve block and trigger point injections leading to temporary relief. The examinations by several physicians suggest that the origin of the patient’s pain is due to a disease, such as a ruptured or protruding thoracic disc. The patient indicates that Botox injections have been beneficial. She has requested authorization for further Botox therapy. The Health Plan has denied the patient’s request indicating the efficacy of Botox has not been established.It appears the patient’s pain is due to a combination of postural changes and muscle spasms.

Where the denial was upheld

Physician 1The patient is a 38-year-old female with a number of medical issues including long- standing muscle tension headaches, degenerative cervical and lumbosacral spine disease, and psychiatric problems. Some of these problems appear to stem from an injury that the patient sustained as the result of a fall in August 2002. The patient has consulted several physicians and has attempted treatment with several different medications. She has received Botox injections that she reports have resulted in relief of her symptoms. She now wishes to continue with Botox injections. The Health Plan has denied authorization and coverage for Botox therapy on the basis that it is considered investigational. To date, the long-term efficacy of Botox injections for treatment of the patient’s medical problems has not been established.

Physician 1: The patient is a 34-year-old female with chronic headache and neck pain for two years after a motor vehicle accident. She has been followed by a pain management specialist who has treated her with narcotics, muscle relaxants, trigger point injections, occipital nerve blocks and botulinum toxin type B (Myobloc) injections. The patient has continued to experience moderate to severe pain. The Myobloc injections on several occasions resulted in modest and short-lasting pain relief. The patient wishes to receive additional Myobloc injections. The Health Plan has denied coverage for Myobloc on the basis it is considered investigational for treatment of migraine headaches.There are very limited studies involving Myobloc in the treatment of headache or neck pain with no placebo-controlled studies.

Put this treatment in the complete diagnosis-and-drug graph, with the migraine-only denominator disclosed separately: 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 Botox Injections, then check the rights and deadlines that apply to your plan.