Getting Insurance to pay for Botox?

By Katinthecorner Wednesday, September 01, 2010

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I'm getting my first Botox treatment in November, and I'm trying to get my insurance to cover it. I know for a fact it is considered investigational (the funny thing is that from 2004 through May 2009 it wasn't and my compay paid for it). I know I'm going to have to pay out of pocket for my treatment when I get it done, but I'm hoping to get my insurer to reimburse the cost in the long run.

I'm actually doing a pre-service appeal. I've written my letter, complete with references to the Phase 3 clinical trials, the UK approval, several journal articles related to my specific symptoms, and a full APA style bibliography. (Let's see what they make of that! HA!) I'm also going to see if I can get my doctor to provide a letter of Medical Necessity for me.

I'm just wondering, has anyone had any luck getting thier insurance to cover Botox on an appeals basis? If so, do you have any tips?

Too sensitive about the use of the word "Migraine"?

Comments (11) | Add comment

Teri Robert, Health Guide

9/ 1/10 2:03pm

Kat,

Here's a thought...

I'm convinced that it's the COST that makes insurance companies deny payment for Botox. Investigational? Give me a break. They pay for medications prescribed off-label all the time.

You can very truthfully say that you're trying to find something that would be effective for Migraine prevention AND covered by them. So, ask them if they would cover gabapentin (Neurontin), an anticonvulsant medication; verapamil, a calcium channel blocker; amitriptyline, a tricyclic antidepressant; cyproheptadine (Periactin), an antihistamine; paroxetine (Paxil) an SSRI antidepressant, and venlafaxine (Effexor), an SNRI antidepressant. That gives you a nice little group of meds that are all used for Migraine prevention and each of which is from a different category of medications.

My guess is that they'd pay for any of those, yet NONE of them are FDA approved for treating Migraine! So, if and when they say, "Yes," you can reply that since they're all still "investigational" for Migraine and prescribed off-label, just as Botox is, you need them to explain why they won't cover Botox.

Obviously, I can't guarantee that this will work, but I know of two cases where it did.

Keep us posted?
Teri

Katinthecorner

9/ 2/10 10:25am

Oh that's a good idea! I'm going to add that to my letter!!!

There is no logical medical reason they can possibly deny me this service. Also, I'm praying the FDA approval goes through in October (which there are hints and murmurs it will) because that will just give another leg to my argument.

Frankly, I'm most excited to show imy letter to Dr Young. He loves how I'm an insanley educated patient. He's going to flip over this letter! LOL.

Teri Robert, Health Guide

9/ 2/10 10:39am

No, there's no good medical reason. I can't prove it, but am convinced it's the $$.

You're right. Dr. Young will love it. I will never forget what he said about educated pateints in an online chat I hosted in 2000 --

Teri

Kendra

9/ 2/10 11:57am

Since July 2007, my insurance company paid 100% of my quarterly Botox treatments. My neurologist sent the letters of medical neccessity, etc.

Just recently they reneged, saying the "person" who originally approved compensation did it wrong and no longer worked there.

Last appt I had, the office informed me they got a letter from ins co denying coverage and demanding over $7,000.00 be paid back for all the treatments the last three years!

I have yet to hear an update, but if they have to pay the ins co., I have to reimbuse the Doctor.

My migraines went from 15+ peppered throughout the month to mangagable ones during my menses and ovultation. Rarely do I have a breakthrough during the month.

Not sure what the outcome is going to be with the ins co but the Doctor made it clear he doesn't want the practice involved in a legal issue.

Anyone have any advice for me?

Kendra

P.S.

I hope all goes well with you. I have injections in my forehead, sides of my head and back of the neck and skull. I can't afford to pay cash, so I've gone to a derm who can treat my forehead and that's affordable. We'll see if it works as well as the all over the head ones. If not, I'll have to, I don't know what.....

Chris Z

9/ 2/10 1:55pm

Kendra,

Start with an appeal, it was approved once, whether that person was in the wrong or not, doesn't matter, ask your doctor's assistance with it as well.

If that does not work, file a complaint with the Insurance Commissioner in your state. Every state has one, and this is specifically the type of job they do.

I filed a complaint for a student policy when they denied mental health benefits. There was NOTHING in the policy regarding "pre-existing" conditions and I actually had not had a break in insurance coverage, so they couldn't pull that game. The insurance commissioner sent a letter to the compaany telling them they needed to pay up.

So, if there is no direct exclusion in your policy, it is always worth fighting for! Go to it!

Kendra

9/ 2/10 2:48pm

Thank you!

Is there a fee assessed to go through those channels?

PinkPatty

9/ 2/10 2:03pm

Hi Kat.

Before I started going to Jefferson Headache in Philly I was going to UMDNJ and when they wanted to do Botox they were able to get it covered because I also have problems in my neck which cause me pain. By putting the request in for botox to treat neck pain (which was possibly causing my headaches which I was there being treated for) it was approved. One key thing the insurance company asked was if I was taking any pain killers for the neck pain. I said I take Tylenol sometimes and that was enough to get it approved.

This might be a thought. Apparently botox is approved for treating neck pain, my xrays show problems in my neck.

I had shots in my forhead, over my ears, in the lower back of my head. It didn't help me at all but I suffer more from chronic daily headaches than from migraines and this really seems to help people more with migraines. I didn't get it done again.

Good luck, I just thought I'd give you another option to try.

Patty

purplekris

9/ 6/10 11:55am

yes my migraine specialist had me get neck xrays to determine any type of 'osis' neck problems so it would be covered. Mine did not show but they covered some of it anyhow. I did not have good experience with the treatment but having the insurance coverage made me be able to try it, since i was only part time at work and paying my own isnurance costs already. good luck.

Getting Insurance to pay for Botox?

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