New efforts to rein in Medicare costs could delay treatment for people who need botulinum toxins for migraine or movement disorders.
Effective July 1, the Centers for Medicare & Medicaid Services will require prior authorization for botulinum toxin injections in hospital outpatient settings. The decision comes despite vocal opposition from the patient advocacy community.
Prior authorization requires patients to secure health plan approval for prescribed treatments before obtaining coverage. In some cases the process can delay access to medicines or procedures for days, even weeks.
The agency’s decision stems from concerns that some health care providers mask cosmetic botulinum toxin treatments as medically necessary therapeutic services. While it’s true that the injections have long been performed for cosmetic purposes, they also treat migraine and movement disorders such as cervical dystonia and blepharospasm. Imposing prior authorization will have the unintended consequence of delaying treatment for patients with these conditions.
In the case of migraine, prior authorization can introduce a variety of complications. This debilitating condition, which disproportionally affects women and veterans, can be difficult to diagnosis and treat. Mismanagement can prompt recurring or more serious symptoms, or lead patients to prescription opioids to reduce the pain.
Poorly managed migraine can also increase visits to the physician, care facilities and the emergency room. Botulinum toxin injections, on the other hand, can help patients and physicians proactively manage the disease, improving quality of life and reducing workplace absenteeism. For patients with migraine, days or weeks spent wading through a complex prior authorization process is too long to wait for relief.
Patients with cervical dystonia or blepharospasm would also suffer from losing timely access to botulinum toxin treatments because of prior authorization. The injections are the first line of care for cervical dystonia, which affects tens of thousands of Americans. Cervical dystonia typically causes painful involuntary contractions in neck muscles. Blepharospasm causes involuntary eye closure that can leave some patients functionally blind.
Alleviating symptoms with botulinum toxin injections can be life changing for these patients. Delays in treatment, on the other hand, can trigger uncontrolled symptoms that interfere with daily life and cause unnecessary discomfort or pain. Patients’ frustration with prior authorization can lead them to abandon treatment altogether.
“This policy undermines the physician-patient relationship by delaying or even denying access to the therapies the provider, relying on evidence and his or her professional judgment, determines to be in the patient’s best interests,” the Alliance for Patient Access noted in a letter to the Centers for Medicare and Medicaid Services.
The process also consumes providers’ time, sometimes forcing them to spend hours filling out and submitting multi-page forms, test results and patient records.
The Centers for Medicare and Medicaid Services’ decision comes as a disappointment, leaving patients with a medical need for botulinum neurotoxin injections unprotected. There is nothing cosmetic or elective about relieving suffering and improving quality of life for people with serious conditions. But for now, patients with legitimate medical need will just have to wait.