USA Botox Games: Insurance Company Strategies to Make the Chronic Migraine Patient Lose

William B. Young, MD, FAHS, FAAN
Vice President, Alliance for Headache Disorders Advocacy
Jefferson Headache Center; Philadelphia, Pennsylvania


In late 2010, the FDA approved Botox for chronic Migraine. In February of this year, it became possible to code and get Botox paid for by Medicare, and insurance companies followed suit a few months later. But they did it reluctantly, and are doing everything they can to deny, delay, postpone, or otherwise impede chronic Migraine patients from getting the only FDA-approved treatment for their disease.

With traditional insurance companies, the criteria for qualifying for Botox are

1) – having chronic Migraine (more than 15 headache days per month), and
2) – failing 3 or more preventives in at least 2 classes (antidepressant, seizure medicine, or blood pressure medicine).

I know the criteria, and I don’t play games and submit patients I know don’t qualify. My patients are usually so overqualified for Botox they should have tried it last century. I have been collecting chronic Migraine patients for 20 years, and many have tried 20 or 30 preventives.

But, unfortunately, Botox is expensive. The drug itself runs about $1100 for the right amount of units, four times a year. So the insurance companies:

Require the doctor to fax tons of records, including all the clinical information from previous physicians, lab & blood tests, medications tried, all clinical information from our facility, and sometimes an additional letter of medical necessity. We send about a half-inch of medical records to most insurance companies.
Don’t read the faxed records. We summarize the record, and use the required verbiage: “The patient has chronic migraine. They have headaches more than15 days per months which are linked to Migraine (the exact wording of the FDA approval). They have failed adequate trials of these antidepressants, these seizure medicines, and these blood pressure medicines, all of which are proven to be effective against Migraine.” They still don’t read it!

Lose faxed material. (Our record is three consecutive lost faxes on the same patient.)

Require the same material faxed for each and every treatment, and require us to prove once again the patient still has chronic Migraine. This gives them an opportunity to once again not find the relevant information they were eventually able to find the last time, or lose the records again. If we have to get a patient re-authorized, we have to re-fax everything we previously faxed for the initial authorization, as well as any other recent office visit notes and/or Botox office visit notes with procedure notes.

Require us to show a percentage change in headache frequency or a reduction in number of hours of headache per month after two injection cycles. So a patient does not get to decide if he or she had meaningful headache improvement. If your daily headache goes from an 8/10 to 3/10, but you don’t have headache-free time, will this be good enough?

Jack up the co-pays. Everybody is experiencing increasing co-pays. Not only might the patient have a co-pay for the procedure itself, which is then added to the regular office visit co-pay, he or she might have a co-pay for the drug through the specialty pharmacy. But with Botox, this is taken to a new extreme. What insurance companies have done for other medical treatments was just practice for what many of them have done for Botox.

Delay decision until after the procedure. Some insurance companies won’t make the determination of whether you meet criteria until after the procedure has been performed. The insurance company not only wants to know how much our facility bills for the procedure, but how much we charge for the drug itself because, ultimately, we have to use our stock, which we have purchased, and bill for it. Imagine: “Have the procedure, and then we will let you know if we will pay or if you are on the hook for over a thousand dollars.”

Is there a vendetta by the insurance companies against chronic Migraine patients, because they are not worthy of an expensive treatment? I don’t know, but that is what it feels like to me.

I think part of the strategy is to make it unappealing to take care of headache patients. If the number of doctors willing to do this procedure is reduced, maybe insurance companies can increase their profits. The AHDA must defend the practice of headache medicine.