Tx For Migraine denials: what the review data shows

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 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

Physician 1The patient is a 47-year-old woman who has experienced severe headaches for the past 20 years. She has been treated by a neurologist with a variety of prophylactic and acute medications that have only been partially helpful. The patient’s neurologist has suggested the use of Botox injections. The Health Plan has denied authorization for Botox therapy on the basis that it is considered experimental. There is limited scientific data available for adequate evaluation of the use of Botox for headache relief. Further critical studies of Botox for the treatment of mixed headache patterns await approval by the Food and Drug Administration. In the case of this patient, it does not appear that standard therapy has been exhausted.

Physician 1: The patient is a 43-year-old female with chronic daily headache and a pituitary microadenoma (possible prolactinoma). She has been tried on Keppra, but the submitted records do not indicate she has tried any of the usual preventive medications. She has not had substantial response to usual acute medications such as triptans and butalbital compound. Her headaches are most consistent with chronic migraine. The patient was recently placed on Depakote, but the response to treatment is not documented. The patient’s provider has recommended a trial of Botox injections as preventive therapy. The Health Plan has denied coverage for Botox on the basis it is considered experimental for treatment of migraine headaches.The patient has chronic migraine.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Tx For Migrainewhen you appeal: reviewers routinely find that denials like yours didn’t hold up.