Editor's note: If you have questions about the practices of your managed-care coverage, ask the experts at the state Department of Managed Health Care. They take up issues ranging from difficulties getting an appointment to denial of a doctor's recommendation for treatment.
My health plan denied Botox injections for me, which were recommended by my neurologist in order to relieve severe muscle spasticity caused by multiple sclerosis.
– Jamsheed Bahar, Orangevale
Best known for its cosmetic uses in reducing the appearance of wrinkles by relaxing a muscle, Botox is also prescribed for relief of migraines and spasms. That includes hand tremors, facial spasms, spasmodic voice disorders and the like.
Health plans typically cover the cost when the drug is used to relieve migraines and spasms. So, why would a health plan refuse to cover Botox injections for a spasm caused by multiple sclerosis?
When health plan representatives review a request for a medication, they look at the health plan's medical criteria, as well as the terms and conditions outlined in the patient's Evidence of Coverage in order to determine whether a drug is covered for a particular use.
Your plan has a list of conditions for which it provides coverage for Botox injections, but muscle spasticity caused by multiple sclerosis is not on the list. Your plan also notes that the Food and Drug Administration has not approved Botox for this specific use.
Whenever an enrollee is denied a treatment because the plan says it is not medically necessary, the enrollee may ask the Department of Managed Health Care to obtain an independent medical review.
In response to your complaint, the DMHC asked an independent physician to make a binding determination on whether it was medically necessary for you to receive a Botox injection to treat your condition.
The reviewer found that you and your doctor had already tried other approaches that were unsuccessful, and that, other than Botox, your remaining option would be surgery to release the muscle.
Based upon these circumstances, the reviewer determined that the health plan's denial should be overturned.
To ask a question, go to www.sacbee.com/ask or write Second Opinion; Features Department; The Sacramento Bee, P.O. Box 15779, Sacramento, CA 95852.
