Use to use Botox, only therapy possible. Now insurer says "cosmetic," and coverage denied. Huh?

A person I know has this nerve disease, whose name I forget, that affects her vocal cords, creates a kind of palsy that makes her sounds like she’s totally overwhelmed, voice quivering like someone on the verge of tears or recounting a recent hugely emotional event–even if she’s just commenting on the weather.
It is episodically, and she’s had it for decades, and now it’s worsening, becoming more frequent. She said that for years when it acted up her doctor gave her a Botox injection in her cords (? someplace in her larynx) which by extremely local paralysis stopped or lessened the shake.

According to her previously shots/doctor was covered under her health insurance, and at some point–presumably after the wrinkle-removing/ruin-my-desire-to-run-off-with-Nicole-Kidman use of the same drug became popular.

This seems incredible to me.

I don’t see why she would lie, but does this sound possible? Has anyone ever heard of anything similar?

What would be a good hyperbolic joke analogy to express outrage at this? (Not so important part of OP, but…)

It sounds like the reviewer is seeing “Botox” and reaching for the REJECT stamp. Since Botox was created for every other use than cosmetic nerve killing, the physician should have treatment codes and the like that specifically assign its use to this non-cosmetic treatment, and the insurer should be evaluating the treatment that way.

If the doctor has been using Botox in an off-the-books way and using the cosmetic treatment codes to cover it, it’s another situation.

If it’s spasmodic dysphonia, Botox appears to be a known treatment for the condition. It might be used off-label, though, rather than being FDA-approved (I couldn’t find anything either way), so she and her doctor should be filing an appeal with the insurance company.

The doctor needs to contact the insurance company for a prior authorization, and get this paid for. Botox has many non-cosmetic uses.

I get Botox for Migraines. I had to try almost everything else first, but it’s covered.

And we have a threadwinner for username+post. :slight_smile:

I suspect the insurance issue boils down to off-label use they won’t pay for, without preapproval.

Of course, this happens all the time and is one of the reasons the US health system is so detestable.