Is Botox for Migraines Covered by Major Medical Insurance?

Question

I have had migraines for over 30 years. Sometimes every night in spring and fall. Will blue cross blue shield cover the cost? What medical documents do I need to take to a dermatologist or plastic surgeon.

Kenneth D. Steinsapir, MD · Answer

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.

Jonathan Cabin, MD · Answer

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.

Otto Joseph Placik, MD · Answer

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

Houtan Chaboki, MD · Answer

Hi redbone5153 in Mcdonough, GA,

	The FDA only recently approved the use of Botox for chronic migraine patients, even though Botox has been used for years to help headaches. Insurance coverage largely depends on your insurance benefits with your insurance provider. It's best to ask your insurance company. Best of luck.

Kevin M. Robertson, MD, FACS · Answer

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).

Ron Shelton, MD · Answer

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.

David Shafer, MD, FACS · Answer

Botox is an effective treatment for headaches. I know because I use it on myself for headaches and it is very effective. Each insurance plan is different and many require treatment with traditional modalities such as medication prior to approving Botox. Good luck.

Anshul Gambhir, MD · Answer

Thank you for your message! Botox for migraines may be covered by your insurance, though this varies greatly per plan. You would have to reach out to your insurance company to see what their policy is. We have a lot of patients who benefit from Botox in terms of reducing their migraines however! I would also recommend a consultation with a provider in your area so you are able to discuss the number of units needed, etc.

David S. Rosenberg, MD · Answer

Most insurance policies require that you have tried several migraine medications without successful alleviation of the migraines. Only after will most insurance companies consider covering botox as treatment for migraines.

Hratch Karamanoukian, MD, FACS · Answer

Although the FDA approved Botox for migraine headaches, your best bet to get it covered by medical insurance is to have it injected by a neurologist. They can justify the treatment with proper medical therapy, and if that doesn't help, recommend Botox and do the tedious paperwork to get your insurance company to authorize the injections for reimbursement.

Is Botox for Migraines Covered by Major Medical Insurance?

Answers (18)

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