Botulinum Toxin denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for botulinum toxin for treatment of the enrollee’s migraines. Findings: The physician reviewer found that The physician reviewer found there is sufficient support for the requested services in this clinical setting. This patient has been treated with an adequate number of preventive medications, without success. Botox has established efficacy, not only in episodic migraine, but also in chronic daily headache as well as mixed headache disorders. The medical evidence supports botulinum toxin in this patient’s case. All told, the requested botulinum toxin is likely to be of greater benefit than other available treatment options.

The patient is a 34-year-old woman who has a prior history of migraine type headaches. She is requesting authorization for Botox therapy. The submitted records indicate the patient has been on nortriptyline, Topamax, Atenolol and Depakote. She has used Imitrex for breakthrough headache activity. The records provided do not demonstrate any evidence that the patient has analgesic dependent headache. Her headache diary indicates headache activity of at least 30% in any given month. She has tried Botox with a reduction in frequency and severity of headache activity. At issue is whether Botox is medically necessary for treatment of the patient’s medical condition.Review of the submitted records indicates the patient has been treated with a number of different prophylactic agents without adequate relief. She meets the clinical criteria for migraine type headache and tension type headache.

Where the denial was upheld

Physician 1The patient is a 64-year-old woman who has been experiencing headaches, cervical muscle spasms, occipital neuralgia, and cervical pain due to cervical spine degenerative disc disease. A number of treatment modalities have been tried without providing satisfactory relief. Injections of botulinum toxin have provided effective relief of pain and muscle spasms. The patient wishes to continue treatment with botulinum toxin. The consultations with her pain specialist indicate that a variety of medications and treatments have been tried since 1/5/04 without significant relief. The patient reports that injections of botulinum toxin provide relief for two months. She wishes to receive additional botulinum toxin injections.

The patient is a 36-year-old female with intractable headaches and spasm of the neck and shoulders. She has requested authorization and coverage for Botox injections. The submitted documentation suggests the patient has failed Maxalt and Cox-2 inhibitors. There is no clear documentation regarding the patient’s current symptoms or degree of disability. The Health Plan has determined Botox is not medically necessary for treatment of the patient’s medical condition.The submitted medical records do not demonstrate the basis for the patient’s underlying disease process. It appears the patient has not undergone usual and customary treatment with physical therapy or tricyclic anti-depressants for chronic neck and head pain. The patient’s MRI reveals a disc herniation and possible cervical nerve root compression, which may be the primary inciting cause of this patient’s pain.

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