Boutlinum Toxin Injection

[Guest javery]

Would Boutlinum Toxin Injection be reimbursable under the Medical Reimbursement Account? This claim was denied due to the fact that it was not recognized as being approved by the FDA. The diagnosis code is for MS.

[Guest MSMA]

Good question...

Normally, if the participant provided a "letter of medical necessity" from their physician, which clearly stated that the treatment was to treat/alleviate a specific medical condition and not cosmetic in purpose, I would allow the claim. Of course, this should also be accompanied by an EOB from the insurance company showing what they did or did not pay and why. Upon occasion, I have had the patient "tell" me that a procedure was therapeutic only to get the EOB showing claim was denied for cosmetic reasons.

HOWEVER, if the FDA has not approved this injection for use in regards to MS, I would probably not allow it either.

What does everyone else say?

[papogi]

Try as I may, the only thing I can find is that medicines that are (1

) available only by prescription (except insulin), and (2) are prescribed by what the Social Security Act considers a physician, and (3) that are not used for cosmetic reasons (botox treatment is usually not cosmetic) and treats an illness, etc. can be reimbursed through a HCFSA. I have found nothing that addresses or requires FDA approval. While that might be a provision written into an underlying health or Rx plan, it does not appear to be a requirement under Section 213 for tax deductibility or FSA reimbursement. I think it should be reimbursed, but I, too, am interested in other opinions...

[mroberts]

I would always err on the side of caution in cases like these. What's the worst case scenario of reimbursing a procedure that a doctor says is necessary versus not reimbursing it and ending up in court? Remember, carriers usually do what's most profitable for them, not what's always best for the employees, thus they are going to deny more expensive forms of treatment. Not having FDA approval makes life a little easier on them in court.

A good example I always use when illustrating a carrier's profit motives are implants. Why aren't implants covered under most dental plans? Because carriers claim they are experimental, right? Well, implants have been done for over 20 years, so at what point is something not considered experimental? Carriers don't want to start covering the procedure because it costs more than a bridge, however, these days only slightly.

You can bet that other procedures could have been done for this employee that were less costly and that's why the carrier is denying the claim. If the doctor prescribed the BTI, and there's nothing saying that the employee was getting the procedure done for kicks, just approve it.

[Guest MSMA]

Just a quickie response here to Papogi (and is NOT intended as a slam in ANY way): Botox is in fact being used for cosmetic purposes. It is the hottest thing (in certain circles) for getting rid of fine lines & wrinkles when a full out face lift isn't done. There are even ladies luncheons where women line up for their injections before/after their turn at the buffet. Whether they are laugh lines or crows feet - it's botox to the rescue!

[papogi]

I realize that botox can, and is, used for cosmetic reasons, and under those circumstances, should not be payable under flex. It's the hot cosmetic thing, and that gets all the publicity, but by volume, the injections are usually used for less vain reasons. The injections were originally not used for cosmetic purposes at all, and the post states that the diagnosis is MS. I assume this is multiple sclerosis (but I could be wrong), for which this drug could be used. I included something from another site which gives some info about Botox:

Botulinum toxin injections -- commonly known as Botox therapy -- have become a very useful tool in the treatment of a number of neurological disorders. Botulinum toxin is a protein substance that is directly injected into muscle tissue in order to stop abnormal muscular contraction. It was first used and approved over ten years ago to treat strabismus (misalignment of the eyes). Since then, it has proven effective at treating blepharospasm and hemifacial spasm. It can also provide relief for a number of other neurological disorders characterized by abnormal muscle contraction, including spasmodic torticollis, oromandibular dystonia, and spasmodic dyphonia.

[SLuskin]

I have also read something recently which showed botox injections useful for children with cerebral palsy. I would go with the diagnosis, and not use the fact that the drug has some cosmetic uses also stop me from reimbursing someone who has submitted medical records stating the condition as MS.