1)
Botulinum Toxin Type A (Botox): QualChoice considers botulinum toxin
type A (Botox) medically necessary for the following conditions:
a)
Strabismus,
including gaze palsies, in accordance with:
i)
Provided
there is vision correctable to 20/50 or better in each eye (separately).
ii)
Botulinum toxin is
indicated for use in strabismus as indicated by the following diagnosis codes:
(10) Other dissociated deviation of eye movements
(11) Unspecified disorders of eye movement
iii)
Except as noted above and
below, botulinum toxin is indicated for strabismus
accompanying diseases, such as:
(1)
Neuromyelitis
optical;
(2)
Schilder’s
disease
iv)
Botulinum toxin is not
recommended for:
(1)
Strabismus when angles
are over 50 prism diopters
(2)
Restrictive strabismus
(3)
Duane’s syndrome with
lateral rectus weakness; or
(4)
Secondary strabismus
caused by prior surgical over-recession
v)
Botulinum toxin treatment
is not indicated for patients with chronic paralytic strabismus, except to
reduce antagonist contractor in conjunction with surgical repair.
b)
Blepharospasm, characterized by intermittent or sustained closure of the eyelids
caused by involuntary contractions of the orbicularis oculi muscle.
(1)
Blepharospasm
c)
Post-facial
(7th cranial) nerve palsy Synkinesis (hemi facial spasms), characterized by
sudden, unilateral, synchronous contractions of muscles innervated by the facial
nerve.
(1)
Other facial
nerve disorders (including hemifacial spasm)
d)
Laryngeal
spasm.
(1)
Laryngospasm
(2)
Voice disturbance,
unspecified; Aphonia
(3)
Voice
disturbance; other (including spasmodic dysphonia)
e)
Focal
dystonia’s, including:
i)
Spasmodic
torticollis when all of the following criteria are met:
(1)
There are
clonic and/or tonic involuntary contractions of multiple neck muscles (e.g.,
sternocleidomastoid, splenius, trapezius and/or posterior cervical muscles); and
(2)
There is
sustained head torsion and/or tilt with limited range of motion in the neck; and
(3)
The duration
of the condition is greater than 6 months; and
(4)
There is no
history of chronic neuroleptic treatments; and
(5)
There is no
associated ataxia, weakness, spasticity, or reflex change; and
(6)
There are no
brain CT abnormalities that would explain the condition;
(a)
And the
diagnosis is:
i.
Spasmodic
Torticollis; or
ii.Torticollis, unspecified; or
iii.
Congenital sternocleidomastoid torticollis
ii)
Lingual dystonia;
f)
Orofacial
dyskinesia
i)
Laryngeal
dystonia (i.e., adductor and abductor spasmodic dysphonia)
(1)
(see
laryngeal spasm Section I paragraph D, above);
ii)
Jaw-closing
Oromandibular dystonia, characterized by dystonic movements involving the jaw,
tongue, and lower facial muscles;
iii)
Hand dystonia
(i.e., organic writer’s cramp);
(1) Organic writer’s cramp
iv)
Symptomatic torsion
dystonia
(1)
Idiopathic torsion
dystonia
(2)
Symptomatic torsion
dystonia
(3)
Fragments of torsion
dystonia
(4)
Fragments of
torsion dystonia; other
g)
Limb
spasticity, including:
i)
Hereditary
spastic paraplegia;
(1)
Hereditary
spastic paraplegia
ii)
Limb
spasticity due to multiple sclerosis;
(1)
Multiple
sclerosis
iii)
Limb
spasticity due to other demyelinating diseases of the central nervous system;
(1)
Other
demyelinating disease of central nervous system
iv)
Spastic
hemiplegia;
(1)
Spastic hemiplegia
v)
Infantile cerebral palsy
h)
Esophageal achalasia, for
individuals who have any
of the following:
i)
Have failed
conventional therapy; or
ii)
Are at high
risk of complications of pneumatic dilation or surgical Myotomy; or
iii)
Have failed a
prior Myotomy or dilation; or
iv)
Have had a
previous dilation-induced perforation; or
v)
Have an
Epiphrenic diverticulum or hiatal hernia, both of which increase the risk of
dilation-induced perforation.
vi)
With
diagnosis code:
(1)
Achalasia &
cardiospasm
i)
Chronic anal
fissure unresponsive to conservative therapeutic measures (e.g., nitroglycerin
ointment).
(1)
Chronic anal
fissure
j)
Focal
hyperhydrosis, when all of the following are met:
i)
Topical
aluminum chloride or other extra-strength antiperspirants are ineffective or
result in a severe rash; and
ii)
Member is
unresponsive or unable to tolerate pharmacotherapy prescribed for excessive
sweating (e.g., anticholinergics, beta-blockers, or benzodiazepines); and
iii)
Significant
disruption of professional and/or social life has occurred because of excessive
sweating.
iv)
With
diagnosis code:
(1)
Focal
hyperhidrosis
k)
Ptyalism/Sialorrhea (excessive secretion of saliva, drooling) that is socially
debilitating and refractory to pharmacotherapy (including anticholinergics).
(1)
Disturbance
of salivary secretion
l)
Facial
Myokymia and trismus associated with post-radiation Myokymia.
(1)
Other facial
nerve disorders
m)
Hirschsprung’s disease with internal sphincter achalasia following endorectal
pull-through.
(1)
Hirschsprung’s disease
n)
Medically refractory
upper extremity tremor that interferes with activities of daily living (ADLs)
(Additional botulinum toxin injections are considered medically necessary if
response to a trial of botulinum toxin enables ADLs or communication).
o)
Overactive bladder (OAB)
with symptoms of urge urinary incontinence, urgency and frequency in adults who
have:
i)
Detrusor over activity
confirmed by urodynamic testing, AND
ii)
Documentation of an
inadequate response to or intolerance to at least two adequately titrated
anticholinergic medications
p)
Detrusor-sphincter
Dyssynergia after spinal cord injury.
q)
Overactive bladder
(detrusor over activity) when all of the following conditions are met:
i)
Detrusor over activity is
confirmed by urodynamic testing, AND
ii)
Documentation of failure
of an adequate trial (three months) of behavioral therapy (first-line treatment
per American Urological Association guidelines), AND
iii)
Documented failure or
intolerance to at least two adequately titrated anticholinergic medications
(second-line treatment per American Urological Association guidelines), AND
iv)
Documented failure or
intolerance to mirabegron, a beta-3 adrenergic agonist (second-line treatment
per American Urological Association guidelines).
r)
Migraines -- for
prevention of chronic (more than 14 days per month with headaches lasting 4
hours a day or longer) migraine headaches in adults who have tried and
failed trials of at least 3 classes of migraine headache prophylaxis medications
of at least two months (60 days) duration for each medication:
i)
Beta Blockers (e.g.
atenolol, propranolol);
ii)
Anticonvulsants (e.g.
topiramate, gabapentin, divalproex);
iii)
Anti-depressants (e.g.,
amitriptyline, venlafaxine);
iv)
Calcium channel blockers
(e.g., verapamil);
v)
Anti-CGRP agents (e.g.,
Aimovig/erenumab)—not to be used with Botox.
2)
Botulinum Toxin Type B (Myobloc): QualChoice considers botulinum toxin
type B (Myobloc) medically necessary for the following indications:
a)
Treatment of
individuals with cervical dystonia (spasmodic torticollis) to reduce the
severity of abnormal head position and neck pain associated with cervical
dystonia;
(1)
See section I
Paragraph E1 above.
b)
Treatment of
spasticity caused by stroke or brain injury.
3)
AbobotulinumtoxinA A
(Dysport):
QualChoice considers AbobotulinumtoxinA A
(Dysport) medically necessary for the treatment of any of the following
indications:
a)
Blepharospasm,
characterized by intermittent or sustained closure of the eyelids caused by
involuntary contractions of the orbicularis oculi muscle.
b)
Cervical dystonia,
(spasmodic torticollis) of moderate or greater severity when all of the
following criteria are met:
i)
Alternative causes of the
member’s symptoms have been considered and ruled out, including chronic
neuroleptic treatment, contractures, or other neuromuscular disorders; and
ii)
There is sustained head
torsion and/or tilt with limited range of motion in the neck; and
iii)
The duration of the
condition is greater than 6 months; and
iv)
There are clonic and/or
tonic involuntary contractions of multiple neck muscles (e.g.,
sternocleidomastoid, splenius, trapezius, and/or posterior cervical muscles).
c)
Limb spasticity,
including:
i)
Equinus Varus deformity
in children with cerebral palsy
ii)
Hereditary spastic
paraplegia;
iii)
Limb spasticity due to
multiple sclerosis;
iv)
Limb spasticity due to
other demyelinating diseases of the central nervous system (including adductor
spasticity and pain control in children undergoing adductor-lengthening surgery
as well as children with upper extremity spasticity);
v)
Spastic hemiplegia, such
as due to stroke or brain injury.
4)
IncobotulinumtoxinA (Xeomin):
Considered medically necessary for the following conditions:
a)
Blepharospasm
characterized by intermittent or sustained closure of the eyelids caused by
involuntary contractions of the orbicularis oculi muscle.
b)
Cervical dystonia,
(spasmodic torticollis) of moderate or greater severity when all of the
following criteria are met:
i)
Alternative causes of the
member’s symptoms have been considered and ruled out, including chronic
neuroleptic treatment, contractures, or other neuromuscular disorders; and
ii)
There is sustained head
torsion and/or tilt with limited range of motion in the neck; and
iii)
The duration of the
condition is greater than 6 months; and
iv)
There are clonic and/or tonic involuntary
contractions of multiple neck muscles (e.g., sternocleidomastoid, splenius,
trapezius, and/or posterior cervical muscles).
5)
Providers must document
the results of and the response to these injections at least after every third
session. Failure of two definitive, consecutive, treatment sessions involving a
muscle or group of muscles could preclude further coverage for same serotype of
botulinum toxin.
Codes
Used In This BI:
J0585
Injection, OnabotulinumtoxinA, 1 unit
J0586
Injection, AbobotulinumtoxinA, 5 units
J0587
Injection, RimabotulinumtoxinB, 100 units
J0588
Injection, IncobotulinumtoxinA, 1 unit
64615
Injection/chemodenervation of muscles innervated by
facial/trigeminal/cervical
spinal/accessory nerves