Diagnosis: Melanoma differentiation-associated protein 5 (MDA5) dermatomyositis with associated Raynaud's.
Treatment: Botox.

The insurer denied coverage for Botox. The denial is overturned.

The patient is a female with a diagnosis of melanoma differentiation-associated protein 5 (MDA5) dermatomyositis with associated Raynaud's. She has failed therapy with prednisone, intravenous immunoglobulin (IVIG), mycophenolate mofetil, hydroxychloroquine, sildenafil, and pentoxifylline. The requested medication is Botox for the fingers for treatment of Raynaud's.

Based on the review of the submitted documentation Botox injections of the digits are medically necessary for the treatment of the patient's Raynaud's associated with her dermatomyositis diagnosis. The patient has failed multiple systemic therapies, including vasodilators, as well as systemic immunosuppressive and anti-inflammatory medications. The control of the Raynaud's of her digits requires a localized therapy. There is sufficient peer reviewed evidence in the medical literature that Botox injections can improve symptoms of digital Raynaud's.

Fregene et al. conclude, "Botulinum toxin type A (BTX-A) significantly improves pain and improves healing in Raynaud's patients with few complications. BTX-A was found to be a safe and useful treatment option for vasospastic digital ischemia." (2)

Given the unique nature of the patient's condition and the failure of multiple systemic therapies, the use of Botox injections to the digits is medically necessary under the medical management of the treating physician.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Botox is overturned. Medical Necessity is substantiated.