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Coverage criteria policies

Botulinum toxins: abobotulinumtoxinA (Dysport®), incobotulinumtoxinA (Xeomin®), onabotulinumtoxinA (Botox®), and rimabotulinumtoxinB (Myobloc®) – Minnesota Health Care Programs

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

Botulinum toxins require prior authorization for select indications from HealthPartners Pharmacy Administration.

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 the criteria below:

Prevention of chronic migraine

Botox for the treatment of chronic migraine headaches may be initially covered when all of the following criteria are met:

  1. Patient must be at least 18 years of age; and,
  2. Prescription must be written by, or in consultation with, a neurologist; and,
  3. Patient must have a diagnosis of chronic migraine, which is defined as ≥ 15 days per month with headache lasting 4 hours a day or longer as supported by clinical documentation; and,
  4. Documentation that the prescriber has conducted a comprehensive review of all of patient’s current medications and rebound headache risk mitigation strategies, which include the following, have been tried and failed (unless contraindicated or inappropriate in order to maintain stable function:
    1. Tapering opioids or barbiturates; or,
    2. Addressing over-/under-utilization of triptans, ergots, combination analgesics; and,
  5. The patient must have tried and failed at least one agent in each of the following therapeutic class (e.g., beta blockers or antiepileptics) at maximum daily dosage or at highest tolerated daily dose and at minimum duration of therapy as supported by pharmacy claims data or other relevant documentation, unless contraindicated.

Drug

Maximum daily dosage

Minimum duration of adherent therapy

Beta blockers – Metoprolol

200 mg

3 months

Propranolol

160 mg

3 months

Timolol

30 mg

3 months

Antiepileptics – Divaloproex

1500 mg

3 months

Topiramate

200 mg

3 months

Initial authorization is for 6 months.

Renewal request may be approved for 6 months if the number of headaches per 30 days is reduced as supported by clinical documentation.

Coverage for all other preparations is off label and requires a prior authorization.

Severe bruxism

Botox may be approved for use of severe bruxism, particularly those with associated movement disorders, when all conservative treatments have failed (mouth guard, oral meds, and physical therapy). Coverage for all other preparations is off label and requires a prior authorization.

Cervical dystonia in adults

Botox, Dysport, Myobloc, and Xeomin may be approved to decrease the severity of abnormal head position and neck pain.

Chronic sialorrhea

Xeomin is FDA approved for the treatment of chronic sialorrhea. Coverage for all other preparations is off label and requires a prior authorization.

Severe primary axillary hyperhidrosis

Botox may be approved to treat severe primary axillary hyperhidrosis that is inadequately managed with topical agents. Coverage for all other preparations is off label and requires a prior authorization.

Upper and lower limb spasticity

Botox and Dysport are FDA approved for upper and lower limb spasticity in adults. Dysport is FDA approved for lower limb spasticity in pediatric patients 2 years of age and older. Coverage for all other preparations is off label and requires a prior authorization.

Strabismus and Blepharospasm

Botox is FDA approved for the treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorders in patients 12 years of age and above. Xeomin is FDA approved for the treatment of adults with blepharospasm who were previously treated with onabotulinumtoxinA (Botox®).

Coverage for all other preparations is off label and requires a prior authorization.

Urinary incontinence and overactive bladder

Botox is FDA approved for the following uses:

  1. 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.
  2. Treatment of overactive bladder in adult patients who have an inadequate response to or are intolerant of 3 anticholinergic medications and mirabegron.

Coverage for all other preparations is off label and requires a prior authorization.

Indications that are not covered

  1. Use of botulinum toxin, type A or type B, will not be approved for cosmetic purposes such as removal of facial wrinkles.
  2. Other conditions not listed in this policy will be reviewed on a case by case basis for coverage.

Approval Length

Authorizations for non-migraine diagnoses can be granted for up to 12 months. Migraine approvals can be granted for up to 6 months. Each subsequent authorization requires documentation verifying the patient’s response to the treatment. The prior authorization will only be granted if the documentation shows a positive response to the treatment.

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 10000 UNIT/2ML SOLN

10454071010

Myobloc 2500 UNIT/0.5ML SOLN

10454071110

Myobloc 5000 UNIT/ML SOLN

00259160501

Xeomin 50 UNIT SOLR

00259161001

Xeomin 100 UNIT SOLR

00259162001

Xeomin 200 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

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 Xeomin (J0588), the following codes do not require prior authorization:

    Codes

    Description

    K11.7

    Disturbances of salivary secretion

    K11.8

    Other diseases of salivary glands

    K11.9

    Disease of salivary gland, unspecified

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

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. https://mn.gov/dhs/partners-and-providers/policies-procedures/minnesota-health-care-programs/provider/types/rx/pa-criteria/botulinum-toxins.jsp

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Policy activity

  • 11/06/2017 - Date of origin
  • 10/01/2018 - Effective date
Review date
  • 05/2018
Revision date
  • 05/07/2018

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