This November, I had just eight days of Migraines and headaches. Why? Because of Botox, purely and simply. The only difference between last November and this November is that I started receiving Botox treatments last December.
I was desperate a year ago. I couldn't do my job well, and I was well along the path to not having a life - again. So, when the Botox treatments started reducing the frequency and severity of my Migraines and even helping with the interictal photosensitivity (between Migraine attacks), I was so happy and so relieved.
Now, advance to the present. My insurance company, Aetna, has just denied payment for my last Botox treatment, despite the fact that it was pre-authorized. Why? Because due to the success of the Botox treatments, I no longer meet the criteria for chronic Migraine. What the hell?
Yes, you read that right. They say that Botox is "experimental" for people with fewer than 14 Migraine and headache days a month, so they denied payment. Here's part of the letter I received:
"Aetna considers onabotulinumtoxinA (Botox) medically necessary for the following condition: Migraines - for prevention of chronic (more than 14 days per month with headaches lasting 4 hours a day or longer) migraine headaches in adults who have tried and failed trials of at least 3 classes migraine headache prophylaxis medications of at least 2 months (60 days) duration for each medication. Botulinum toxin is considered experimental and investigational for migraines that do not meet the above-listed criteria."
I cannot, WILLnot accept the damage to my health and quality of life that would result from not being able to continue with Botox treatments for my Migraines. If I had to live with 25 days a month, the result would be having to quit working and apply for disability. AND, something Aetna is failing to take into account is that if I have to stop Botox, my Migraine and headache days increase to the point of their being willing to cover Botox treatments again, it might not work. It's well known that if an effective preventive is discontinued, it might not work when tried again. I went through that with Zongran. That's one of the reasons we went to Botox.
My plan is to start with a conversation with someone at Aetna next week. If I have to go through their appeal process, I will. If they again deny coverage, I'll hire an attorney.
I'll keep you posted on what happens with this.
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© Teri Robert, 2013
Last updated December 21, 2013.