Insurance denial for botox

[HerMajesty]

Hey, does anyone have any literature or suggestions to counter this insurance denial for botox to piriformis?

Dr. Filler suggested piriformis injections after MRN as my piriformis muscles are bipartite (split) and very tight. I had them injected with steroid (approved without a problem by same insurance), but that only put me into a flare and gave me sciatica. I really want to try botox because if I can rule out the piriformis as the culprit by relaxing it with no result, I will know for sure i need tarlov cyst surgery; whereas if relaxing the piriformis relieves my symptoms I will be able to avoid the surgery. Tarlov cyst treatment is major neurosurgery so I think it only makes sense to try this 1st.

Here is the wording of the denial; my Doc is trying to do a peer-to-peer but if that doesn't work I wil need to fight it myself and would appreciate suggestions:

""Botox injections for this condition which includes myofascial pain syndrome, low back pain, and anismus (pelvic floor dyssynergia) is considered investigational. Studies in the medical peer review journals for the piriformis myofascial pain syndrome do not support conclusions about the effects of the botulinum toxin. The medical information made available shows that you have piriformis muscle and pelvic pain. The reason for the decision is based upon out Medical Policy (DRUG.00006.Botulinum Toxin)"

I can argue a good case for myself if necessary but it would be particularly helpful if anyone has peer review literature to counter their claim that botox use for pelvic pain is not supported.
Thanks

[Karyn]

Hi HM!
Do you happen to have BC/BS insurance? That was pretty much the wording I got in response when seeking approval a couple of years ago. And BC/BS would NOT budge. I'll have to go back and look at my records because they did list a bunch of stuff they would cover the injections for. With that in mind, do you have a doc that would work with you for the diagnostic codes?
Wishing you the best ...
Love,
Karyn

[HerMajesty]

Yep, that is it, the dreaded BC/BS.

So far this Doc and his staff has been great but the problem about him fighting my battles for me is that I came to him needing this one procedure only, not as a regular client. My regular pain guy is a PA who works out of an Osteopathic pain clinic and they don't do any of these kinds of injections, so I am being farmed out to some poor guy who has met me once.

I do think the codes can be worked on though since I have neuropathy in my toes and reduced ankle reflexes which Dr. Filler said are due to sciatic nerve, plus some more classic intermittant sciatica since those steroid injections; so the question becomes if I use the sciatic symptoms to plead more classic "piriformis syndrome" will they be less un-budgeable about that?

I had been anticipating having to pay for my own botox vial but not the entire procedure.

What was your outcome, Karyn? Did you do it on your own dime or give up the botox idea?

[ezer]

I had BC/BS too and they wouldn't pay for Botox. They did pay for outpatient services at the medical facility that Dr.Jordan uses.

[HerMajesty]

I had BC/BS too and they wouldn't pay for Botox. They did pay for outpatient services at the medical facility that Dr.Jordan uses.

Did you have to fight for the outpatient hospitalization, or did they just grant it? I am pretty sure Dr. Jordan does not take insurance but the guy I am using is in-network. I would be thrilled just to have them pay the facility and pay the doc to stick the needle in me. I'll cover the cost of the botox vial...I hear it costs less than 50 cents to make a vial of botox and it retails for $500 to $800 per vial. But still i expected to eat that cost. I just can't afford to use all my reserves on covering the total procedure, as i will need the reserves if it turns out I need the tarlov surgery.

[ezer]

I had BC/BS too and they wouldn't pay for Botox. They did pay for outpatient services at the medical facility that Dr.Jordan uses.

Did you have to fight for the outpatient hospitalization, or did they just grant it? I am pretty sure Dr. Jordan does not take insurance but the guy I am using is in-network. I would be thrilled just to have them pay the facility and pay the doc to stick the needle in me. I'll cover the cost of the botox vial...I hear it costs less than 50 cents to make a vial of botox and it retails for $500 to $800 per vial. But still i expected to eat that cost. I just can't afford to use all my reserves on covering the total procedure, as i will need the reserves if it turns out I need the tarlov surgery.

It was not a problem for the medical facility. It happened automatically which was a pleasant surprise. For Dr.Jordan and Botox, it was denied. I did not insist too much to be honest as I was doing very poorly after the injections.

[Karyn]

I didn't personally file for an appeal for the botox, but the UroGyn I was seeing at the time did, on my behalf. BC/BS still wouldn't budge. I have to say I'm not sorry. I really didn't know anything about it at the time and probably wouldn't have considered it, knowing what I know now. It's just not for me.
Best of luck!

[HerMajesty]

It'll probably come down to me writing one of my infamous nastygrams and i'll let everyone know how it turns out. I really do tend to get what I want when i take the time to write...and I have the free extended 100,0000 mile bumper to bumper warranty on my car to prove it So this will be the test case: can BC / BS be badgered into a botox approval? If I can't do it, I doubt it can be done

[ezer]

I didn't personally file for an appeal for the botox, but the UroGyn I was seeing at the time did, on my behalf. BC/BS still wouldn't budge. I have to say I'm not sorry. I really didn't know anything about it at the time and probably wouldn't have considered it, knowing what I know now. It's just not for me.
Best of luck!

Probably a selective Botox injection in 1 muscle will be fine. For me however the after Botox reaction was significantly worse than my surgery recovery. It was shocking as it was sold as the ultimate new, safe, and non-invasive pain management option by many when I had it.

[TracyB7777]

Hmmmmm, I spoke with my insurance last week and they said it would not be a problem covering the botox and the procedure. I was rather surprised. I'm scheduled for my MRI with Dr. K (in Phoenix) on April 26th and Botox on April 28th with Dr. Hibner. I have a call in to Dr. Hibner's office to make sure everything is covered by insurance. I'll keep you posted. Maybe we can use each other as case studies for the different insurance companies.