Diagnosis: Chronic Migraine Headache Disorder.
Treatment: Botox Treatment.
The insurer denied the request for Botox Treatment.
The health plan's determination is overturned.

The patient is a female with chronic migraine headaches. Treatment with Botox is the subject of this review. The drug was denied because the patient has not tried and failed multiple oral preventative medications. However, records indicate that the patient has not responded to Gabapentin, Amitriptyline, Sertraline, Metoprolol, Labetalol, or Cyclobenzaprine for the prevention of migraine headaches. The denial of Botox was appealed.

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

Yes, the requested service/treatment of Botox treatment is medically necessary for the patient. The patient has chronic migraine headaches. Chronic migraine is a Food and Drug Administration (FDA) approved indication for treatment with Botox. The FDA and manufacturer do not require that a patient has failed any first-line therapies prior to Botox therapy. However, the information supplied for review indicates that the patient has tried and failed Labetalol, Metoprolol, Gabapentin, Amitriptyline, Sertraline, and Cyclobenzaprine. This includes a number of first line and second-line oral preventative therapies. These have been ineffective.

The health plan's determination of medical necessity is overturned in whole.