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.