Is Botox for Migraines Covered by Major Medical Insurance?

Please recognize that the FDA approval was for individuals with chronic migraines.  The benefit was only seen in individuals who suffer from migraines more than 15 days per month.   The increase in migraine free days was seen in both the study patients who received placebo and those who received the BOTOX but the BOTOX patients had moderately more days migraine free than those who received placebo.  A significant amount of BOTOX was needed to achieve migraine improvement: 150 units.  Also 1 percent of participants in the study experienced a worsening of the migraines.  2 percent of study participants dropped out of the study due to side effects.  Will this treatment be right for you?  It is likely that your insurance company will be looking for significant documentation before they agree to pay for these treatments so be certain to get the appropriate prior authorization.  It is also likely that the insurance company will not allow your cosmetic surgeon to perform this type of treatment but rather will be looking to see that you are being treated by a neurologist to prevent fraud and abuse.  

As with most insurance-related questions, this all depends on a number of factors:

1) The insurance company - some insurance companies are more likely to pay than others.

2) The patient - many insurance companies will only pay for Botox if the patient meets the very specific criteria set forth by the FDA, when Botox was approved for migraine headaches in 2010. This includes 15 or more headaches per month, and 4 or more hours per headache. 

3) The amount - many insurance companies will reimburse only if the exact amount of Botox recommended by this same FDA study: 155 units over 7 muscular sites. If more or less is used, the claim could be rejected (even though many patients are known to not require the full amount)

4) The frequency - many insurance companies will pay for Botox only every 3 months, although some patients may require it more frequently.

5) The price - many Botox experts do not participate in insurance, and charge more than the insurance company is willing to pay. So even if your insurance company pays, you may be responsible for the difference between what the insurance company pays and what the doctor charges.

Regardless of the above factors, insurance companies typically respond to well-organized documentation and persistent follow up.

This was recently approved as a recognized treatment option and so the reimbusement patterns have not been not been completely elucidated. 

As you can see, it depends on your location and your insurance plan, as well as some of the coding used by your provider.  In Wisconsin, it doesn't matter what kind of doc you are, ie there is no bias against plastic surgeons.  That's because botox for migraines can be performed by rehab med docs, neurologists, chronic pain docs, anesthesia, or internal medicine.  My suggestion, however, is to stick with "core" physicians for those with the most experience with botox: plastic surgery, facial plastic surgery, oculoplastic surgery, or dermatology.

Overall trends regarding insurance coverage are on the decline.  In my experience here in Wisconsin, we fought for coverage and saw steady iimprovement from the late 1990's through mid 2000's.  In the last three years that has clearly been reversed, to the point that it is exceptional to get coverage at this point.  Sad, but true.  Especially since it is effective for those properly screened,  in the majority of cases.  Most patients also had to first  prove "failure or significant side effects" using other meds like beta blockers and imitrex. 

Call the benefits number on the back of your insurance card and ask them directly if Botox for migraines is a covered expense, as well as if there are restrictions (provider, frequency, proof of prior treatments). 

Some insurance carriers may reimburse partially the cost for Botox for migraines. You would need to check with your individual insurer and they may grant precertification, however, they will tell you that they donot guarantee payment, even if they do precertify it.

Some chronic migraine sufferers who have failed traditional migraine treatments will benefit from Botox. I have several patients who have had life changing benefits from Botox. About half of their insurance companies cover the treatment the other half, unfortunately, need to pay out of pocket. It is possible that the recent FDA approval will help obtain authorization for this treatment in certain patients. Seek out an experienced injector since Botox treatment of migraines is not the same as cosmetic wrinkle treatments with Botox.
Best,Stephen Weber MD, FACS