When you have to deal with a long-term medical condition such as recurring migraine pain, you might find yourself in a dilemma regarding paying for treatments. On one hand, you have the ongoing expense of costs for migraine medication, and on the other the potentially big, upfront cost of surgery. Surgery may or may not reduce your monthly bills for pain meds, but finding a solution to the dilemma through affordable treatment plans can be a struggle.
Will Migraine Surgery be Covered by Insurance?
Migraine is often called the silent disease. It’s mostly invisible to onlookers, who can assess your discomfort only through your reported pain level and stated symptoms. Unlike a broken leg or a fevered brow, there’s little showing on the outside to prove migraine’s debilitating effects.
Because of the difficulty in physically proving migraine, insurance companies have developed a wary attitude towards anyone requesting migraine treatment, especially those such as Botox injections which can bring beneficial side-effects such as reducing frown lines and wrinkles.
Genuine migraine sufferers may request treatments that won't benefit them, while those who imagine migraine claims could open a doorway to cosmetic procedures may do so too. As complex as it is, migraine has no single cause or cure. What works for one person may fail with another, so each patient must be assessed individually and go through the process of gaining insurance approval. It can be frustrating, which is one reason (apart from getting the best medical care possible) why you need an expert care team on your side.
Insurance policies from many companies will cover migraine treatments, but often require prior authorization. This is also called pre-determination or pre-certification.
What is Prior Authorization?
Some insurance companies use a form of prior authorization called step therapy, which works like this:
- First, patients must try the less expensive medications from the company’s drug list or formulary. These are the most common medications that have already proven effective for many migraine sufferers.
- If that medication doesn’t work for you when you have given it a reasonable trial period, you can ‘step’ up and try more expensive drugs.
- To be considered for further interventions, such as Botox treatments or surgery, those other drugs must have also failed to help.
As well as the above clinically measured steps, insurance companies will often want to see proof that you’ve tried non-medication ways to alleviate suffering. These include identifying and avoiding triggers, taking preventive courses of action and making any necessary lifestyle changes.
Practical Steps to Faster Prior Authorization from Your Insurance Company
There are things you can do to strengthen your case and get the medical or surgical treatments you need faster, such as:
- Know Your Insurance Carrier’s Formulary. Insurance companies regularly change and update their drug lists or formularies. Unless you keep up to date with the current list, you may find a medication you regularly rely on is suddenly unavailable to you, or you may not be aware of new drugs that become available. The lists are not secret, and are relatively easy to get hold of. Some companies post them on their website, and if not they will mail you a copy. Use the list to deepen your understanding of your care options and open discussion with your doctor.
- Make Friends with the Doctor and his or her Nurse. These specialized people can be your best advocates when they have thorough knowledge of what works for you and are aware of your medication history. You also have a person to contact if any issues crop up over prescription difficulties.
- Find the Best Insurance for You. Compare policy details between insurance companies before you renew your existing policy. Formularies differ between insurers, and you may find a treatment denied by one company is available from another.
- Make Connections with People at your Insurance Company. Migraine is a more common condition than many realize, with estimates that one in four household have someone with migraine. There is a good chance that someone in the insurance company who deals with your claim is living with a migraine sufferer and, therefore, has a personal understanding. Their deeper sympathy can help you navigate the insurance challenge when you’re looking for cover for migraine surgery.
You can be your own best advocate by learning as much as possible about the insurance process, and by making sure your care team includes trained professionals with experience in migraine treatment and surgery. Medical insurance will cover migraine surgery, and getting authorization will happen faster when you and your care team know how to navigate the system.