Botox and Migraine

[sspa3]

I am a neurology PA in Utah and our practice is interested in starting Botox for migraines now that it is FDA approved. Has anyone had experience using Botox for migraine prophylaxis? If so, in your experience, have the outcomes been positive? Have there been any downsides?

[jmj11]

I do Botox routinely and have for about 8 years. The patient whom I do it on, thus far, have failed most other treatments, so it is a hard group. Of that group, about 50% see enough improvement to continue. For some it is the best treatment they've ever tried and others it just gives an additional benefit such as reducing the level of their daily headache from a 7 to a 5. The only adverse out comes have been two patients with droopy eyelids.

 

Down side? Probably the hassles of getting insurance approval. I thought that things might get easier now that it has FDA approval for Chronic Migraine but the opposite might be true. I've been meeting with the Allergan insurance liaison and the insurance companies are telling them that they are scared that the flood gates are going to open. To avoid that, they are talking about picking just a few providers in each state which they will reimburse for Botox.

[wilso2ar]

I would agree with above. I work in PM&R, Some patient get great relief some not so much. All have failed more conservative and less expensive treatments. In Michigan Priority health allows neurologists and PM&R to use botox without prior auth., so we have been using Botox in them for a while. It is so effective in some that they actually cash pay for it!

 

I do have a question about reimbursment though. Jmj do you have any issues with reimbursment? I was told by the billing department for Allergan that they did not advise PAs using Botox due to the possibility of not getting paid by insurance. Have you experienced this and how is the billing done? do you bill under your sp or yourself. I basically had to teach our billers how to bill for me so they are of little help. Thanks.

[jmj11]

I would agree with above. I work in PM&R, Some patient get great relief some not so much. All have failed more conservative and less expensive treatments. In Michigan Priority health allows neurologists and PM&R to use botox without prior auth., so we have been using Botox in them for a while. It is so effective in some that they actually cash pay for it!

 

I do have a question about reimbursment though. Jmj do you have any issues with reimbursment? I was told by the billing department for Allergan that they did not advise PAs using Botox due to the possibility of not getting paid by insurance. Have you experienced this and how is the billing done? do you bill under your sp or yourself. I basically had to teach our billers how to bill for me so they are of little help. Thanks.

 

For the insurers who pay for Botox, I've never had a problem getting it reimbursed. When I first started, the insurers stated that Botox must be done by a neurologist. I wrote them letters and put together a form letter (which I modify for each patient) and it has never been a problem. I explain my credentials and make it clear that if I can't do Botox, then my only choice is to send them to a headache clinic in Seattle where I'm confident that they will do Botox (as the patient had failed everything else) and those clinics will charge double what we do (due their facility fee etc) plus they would have to enter that system as a new patient, which would about $400. However, we will have to see how this plays out in the new approval environment.

[sspa3]

Thank you for your responses. Did your supervising docs train you or is there some type of training available? Is it sort of a see one, do one type process? None of my sp's currently do Botox, so they would need training as well. How many sites do you inject and what amount of Botox do you use? Do you think the Allergan rep would be a good place to start? Reimbursement may be the challenge. But, as mentioned above, some people are desperate and if an alternative option is available that they may benefit from, I'm open to it.

 

While on the headache subject--do either of you have experience with IV DHE for treatment of withdrawal from CDH caused by medication overuse?