Skip to main content
HealthPartners

Coverage criteria policies

Botulinum toxins: abobotulinumtoxinA (Dysport®), incobotulinumtoxinA (Xeomin®), onabotulinumtoxinA (Botox®), and rimabotulinumtoxinB (Myobloc®)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Use for migraines, hyperhidrosis and off-label indications will not be covered without prior authorization from HealthPartners Pharmacy Administration.

Quantity limits may apply to all claims, as described below.

Coverage

Coverage for botulinum toxin preparations is subject to the indications listed below, and per your plan documents.

Botulinum toxin preparations are covered as follows based on indication:

Prevention of chronic migraine

Botox requires a prior authorization but will generally be approved when the following criteria are met:

  1. Prescribing by a headache specialist who has received training in the injection technique.
  2. Chronic migraine (defined as ≥ 15 headache days/month lasting ≥4 hours a day) despite standard treatment including three or more preventive treatments. Three preventive treatments means trial and failure, or medical contraindications to one agent in three or more of these drug categories.

    Drug Category

    Example Agents

    Beta-blockers

    Metoprolol, propranolol, timolol

    Calcium channel blockers

    Verapamil, nifedipine

    Anticonvulsants

    Topiramate, valproate, gabapentin

    Antidepressants

    Amitriptyline, nortriptyline, doxepin, venlafaxine

Coverage for all other preparations is off label, requires a prior authorization and will be reviewed on a case by case basis.

Severe axillary hyperhidrosis

Botulinum toxin use for hyperhidrosis requires prior authorization. Botox is FDA approved for use in severe axillary hyperhidrosis. Coverage for all other preparations and all other forms of hyperhidrosis is off label, requires a prior authorization and will be reviewed on a case by case basis.

Cervical dystonia

All preparations are covered and do not require prior authorization.

Upper and lower limb spasticity

Botox, Dysport, and Xeomin do not require a prior authorization for this use.

Coverage for all other preparations is off label, requires a prior authorization and will be reviewed on a case by case basis.

Strabismus

Botox does not require a prior authorization for this use.

Coverage for all other preparations is off label, requires prior authorization, and will be reviewed on a case by case basis.

Blepharospasm

Botox and Xeomin do not require a prior authorization for this use.

Coverage for all other preparations is off label, requires prior authorization, and will be reviewed on a case by case basis.

Urinary incontinence and overactive bladder

Botox does not require a prior authorization for this use.

Coverage for all other preparations is off label, requires prior authorization, and will be reviewed on a case by case basis.

Chronic sialorrhea

All agents require a prior authorization for this use.

Xeomin will generally be approved for chronic sialorrhea in adult patients resulting from Parkinson’s disease, atypical parkinsonism, stroke, or traumatic brain injury when present for at least three months.

Coverage for all other preparations is off label, requires prior authorization, and will be reviewed on a case by case basis

Indications that are not covered

  1. Cosmetic use (the treatment of glabellar/canthal lines or wrinkles) is not considered medically necessary.
  2. Other conditions not listed in this policy will be reviewed on a case by case basis for coverage.
Botulinum toxin Quantity Limits

All requests for doses exceeding the FDA-approved regimen will not be covered.

Definitions

Botulinum toxin is an acetylcholine release inhibitor and a neuromuscular blocking agent. It is a purified neurotoxin that acts at the neuromuscular junction to produce flaccid paralysis. Each preparation has the following indications and dosing:

Botox (OnabotulinumtoxinA)

  • Treatment of overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and frequency, in adults who have an inadequate response to or are intolerant of an anticholinergic medication.
  • Treatment of urinary incontinence due to detrusor overactivity associated with a neurologic condition (e.g., spinal cord injury (SCI), multiple sclerosis (MS) in adults who have an inadequate response to or are intolerant of an anticholinergic medication.
  • Prophylaxis of headaches in adult patients with chronic migraine (≥15 days per month with headache lasting 4 hours a day or longer)
  • Treatment of spasticity in adult patients
  • Treatment of cervical dystonia in adult patients, to reduce the severity of abnormal head position and neck pain
  • Treatment of severe axillary hyperhidrosis that is inadequately managed by topical agents in adult patients
  • Treatment of blepharospasm associated with dystonia in patients ≥12 years of age
  • of strabismus in patients ≥12 years of age

Safety and effectiveness have not been established for the prophylaxis of episodic migraine (14 headache days or fewer per month), treatment of upper or lower limb spasticity in pediatric patients or for treatment of hyperhidrosis in body areas other than axillary.

Dysport (AbobotulinumtoxinA)

  • The treatment of adults with cervical dystonia patients
  • The treatment of limb spasticity in adults
  • The treatment of lower limb spasticity in pediatric patients 2 years of age and older

MyoBloc (RimabotulinumtoxinB)

  • Treatment of adults with cervical dystonia to reduce the severity of abnormal head position and neck pain associated with cervical dystonia

Xeomin (IncobotulinumtoxinA)

  • Treatment of upper limb spasticity in adult patients
  • Treatment of adults with cervical dystonia
  • Treatment of blepharospasm in adults previously treated with onabotulinumtoxinA (Botox)

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS Codes

Codes

Description

J0585

Injection, onabotulinumtoxinA, 1 unit (Botox)

J0586

Injection, abobotulinumtoxinA, 5 units (Dysport)

J0587

Injection, rimabotulinumtoxinB, 100 units (Myobloc)

J0588

Injection, incobotulinumtoxinA, 1 unit (Xeomin)

NDC Codes

Codes

Description

00023114501

Botox 100 UNIT SOLR

00023392102

Botox 200 UNIT SOLR

15054053006

Dysport 300 UNIT SOLR

15054050001

Dysport 500 UNIT SOLR

10454071210

Myobloc 10,000 UNIT/2ML SOLN

10454071010

Myobloc 2,500 UNIT/2ML SOLN

10454071110

Myobloc 5,000 UNIT/2ML SOLN

00259161001

Xeomin 100 UNIT SOLR

00259162001

Xeomin 200 UNIT SOLR

00259160501

Xeomin 50 UNIT SOLR

ICD-10-CM Codes
The following diagnosis codes do not require prior authorization for any botulinum toxin products. Quantity limits may apply.

ICD10

Description

G04.1

Tropical spastic paraplegia

G24.01

Drug induced subacute dyskinesia

G24.02

Drug induced acute dyskinesia

G24.09

Other drug induced dystonia

G24.1

Genetic torsion dystonia

G24.2

Idiopathic nonfamilial dystonia

G24.4

Idiopathic orofacial dystonia

G24.8

Other dystonia

G24.9

Dystonia, unspecified

G25.0 – G25.2

Other extrapyramidal and movement disorders

G25.3

Myoclonus

G25.89

Other specified extrapyramidal and movement disorders

G51.0

Bell’s palsy

G51.1

Geniculate ganglionitis

G51.2

Melkersson’s syndrome

G51.3

Clonic hemifacial spasm

G51.4

Facial myokymia

G51.8

Other disorders of facial nerve

G51.9

Disorder of facial nerve, unspecified

G82.20-G83.34

Paraplegia (paraparesis) and quadriplegia (quadriparesis)

G83.4

Cauda equine syndrome

I69

Sequelae of cerebrovascular disease

J38.5

Laryngeal spasm

K11.7

Disturbances of salivary secretion

K22.0

Achalasia of cardia

K59.4

Anal spasm

K60.1

Chronic anal fissure

K60.2

Anal fissure, unspecified

R25.0

Abnormal head movements

R25.1

Tremor, unspecified

R25.2

Cramp and spasm

R25.3

Fasciculation

R25.8

Other abnormal involuntary movements

R25.9

Unspecified abnormal involuntary movements

R29.891

Ocular torticollis

R49.0

Dysphonia

R49.8

Other voice and resonance disorders

R49.9

Unspecified voice and resonance disorder

S04.011S

Injury of cranial nerve, sequela

S04.50XA

Injury of facial nerve, unspecified side, initial encounter

S04.51XA

Injury of facial nerve, right side, initial encounter

S04.52XA

Injury of facial nerve, left side, initial encounter

S06.0x0S – S06.9x9S

Intracranial injury, sequela

S14.0xxS – S14.9xxS, S24.0xxS-S24.9xxS, S34.01xS-S34.9xxS

Injury of nerves and spinal cord, sequela

For Botox only (J0585), the following codes do not require prior authorization:

Codes

Description

N31.0

Uninhibited neuropathic bladder, not elsewhere classified

N31.1

Reflex neuropathic bladder, not elsewhere classified

N31.9

Neuromuscular dysfunction of bladder, unspecified

N32.81

Overactive bladder

N36.44

Muscular disorders of urethra

N39.41

Urge incontinence

N39.46

Mixed incontinence

H49.00-H51.9

Strabismus and other disorders of binocular eye movements

For Botox. Dysport and Xeomin (J0585, J0586, J0588), the following codes do not require prior authorization:

Codes

Description

G11.4

Hereditary spastic paraplegia (limb spasticity due to)

G24.3

Spasmodic torticollis

G35

Multiple sclerosis (limb spasticity due to)

G36.0-G37.9

Other acute disseminated and demyelinating diseases of CNS (limb spasticity due to)

G80.0-G80.9

Cerebral palsy

G81.10-G81.14

Spastic hemiplegia

For Botox and Xeomin (J0585 and J0588), the following codes do not require prior authorization:

    Codes

    Description

    G24.5

    Blepharospasm

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

All other diagnosis codes require prior authorization.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Botox prescribing information. Allergan, Inc. 4/2017.
  2. MyoBloc prescribing information. Solstice Neurosciences, Inc. 1/2012.
  3. Dysport prescribing information. Ipsen Biopharm Ltd. 12/2016.
  4. Xeomin prescribing information. Merz Pharmaceuticals, LLC. 12/2015.

Go to

Policy activity

  • 10/01/1996 - Date of origin
  • 05/07/2018 - Effective date
Review date
  • 05/2018
Revision date
  • 05/07/2018

Related content