Diagnosis: Central Nervous System/Neuromuscular Disorder (chronic migraines).
Treatment: Pharmacy/Prescription Drugs (Botox).

The insurer denied Pharmacy/Prescription Drugs (Botox) for medical necessity. The denial was upheld.

This is a female who was prescribed Botox to treat chronic migraines. 200 units of Botox were administered. An office note indicates that headaches, neck pain and right foot pain were overall better. Current medications were Namenda, candesartan, Ajovy and Botox. She was willing to taper off Namenda. Botox 200 units was administered.

A letter of medical necessity from the patient's neurologist indicates that the patient had been receiving Botox every three months. She had previously tried and failed Keppra, amitriptyline, and Calan.

155 units of Botox were approved for four sessions. This is a total of 620 units of Botox. The additional 180 units (or 45 units per session) have not been approved. This is the subject under review.

The health plan's determination is upheld in whole.

No, the additional Botox units are not medically necessary for this patient.

Under specific review is the dosing of Botox. The issue was dosing of 200 units versus 155 units. Botox is United States Food and Drug Administration (FDA) approved at a dose of 155 units. There is evidence-based, positive clinical trial data at a dose of 155 units. The safety and the improved efficacy of higher doses has not been established in the medical literature. Therefore, the higher dosing is not medically necessary.