CurrentAetnaPolicy N/A

Dysport (abobotulinumtoxinA) Injectable Medication Precertification Request Form

This document is the Aetna precertification request form for Dysport injectable medication used to request initiation or continuation of therapy across several indications; it governs what clinical and administrative information providers must supply for prior authorization.

Policy Summary

PayerAetna

PolicyDysport (abobotulinumtoxinA) Precertification Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest prior authorization from Aetna using this precertification form and provide complete clinical documentation, required diagnosis codes, and a signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2form length

multiplelisted clinical indications

requiredsignature

Aetna-onlypayer contact

Coverage Criteria for Dysport (abobotulinumtoxinA)

Indications requiring clinical documentation

Precertification requests must include indication‑specific clinical information and the associated clinical questions on the form. Provider must indicate the primary diagnosis and complete the clinical items for the selected indication.

Covered indications listed on form: Blepharospasm (including blepharospasm associated with dystonia and benign essential blepharospasm); Cervical dystonia (e.g., torticollis); Chronic anal fissure; Excessive salivation (chronic sialorrhea); Hemifacial spasm; Limb spasticity (upper or lower, including focal spasticity or equinus gait due to cerebral palsy); Primary axillary hyperhidrosis

Provider must indicate the primary diagnosis and complete the associated clinical questions for the selected indication

Prior therapy / refractory requirements

For certain indications, the form requires documentation that first‑line or conservative therapies have been tried and were ineffective before initiating Dysport.

Chronic anal fissure prerequisites: Documentation that the patient failed to respond to first‑line therapy for chronic anal fissures such as topical calcium channel blockers or topical nitrates.

Policy Summary

PayerAetna

PolicyDysport (abobotulinumtoxinA) Precertification Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest prior authorization from Aetna using this precertification form and provide complete clinical documentation, required diagnosis codes, and a signature.

SourceLink

On This Page

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Form includes a checkbox asking whether patient failed first‑line therapy

Axillary hyperhidrosis prerequisites: Documentation that the patient tried topical aluminum chloride or other extra‑strength antiperspirants and that they were ineffective or resulted in a severe rash; documentation that excessive sweating causes significant disruption of professional and/or social life.

Form contains questions about prior topical therapy, effectiveness/adverse reaction, and life impact

Excessive sialorrhea prerequisites: Documentation that the patient is refractory to pharmacotherapy (e.g., anticholinergics).

Form asks whether patient is refractory to pharmacotherapy

Prescriber specialty/consultation expectations

The form requests the prescriber's specialty or documentation of consultation for specific indications.

Required prescriber specialties: Blepharospasm: neurologist or ophthalmologist; Cervical dystonia: neurologist, orthopedist, or physiatrist; Chronic anal fissure: gastroenterologist, proctologist, or colorectal surgeon; Excessive salivation (chronic sialorrhea): neurologist or otolaryngologist; Hemifacial spasm: neurologist, orthopedist, or physiatrist; Limb spasticity: neurologist, orthopedist, or physiatrist; Primary axillary hyperhidrosis: neurologist, dermatologist, or internist.

Form contains checkboxes to confirm prescriber specialty or consultation

Continuation therapy criteria

Continuation (renewal) requests must demonstrate prior benefit from the requested drug.

Continuation of therapy: For continuation requests, documentation that the requested drug was effective for treating the diagnosis or condition is required (form asks 'Was the requested drug effective?' with Yes/No).

Date of last treatment is requested for continuation vs initiation

The form explicitly asks whether the therapy is being prescribed for cosmetic purposes (for example, treatment of wrinkles or uncorrected congenital strabismus with no binocular fusion). This question is required for all precertification requests and is used to identify uses that may be excluded from coverage. Providers must answer the Yes/No cosmetic-use question on the clinical information section of the form.

The clinical information section contains a mandatory checkbox asking whether the requested therapy is for cosmetic purposes with a required Yes/No response. Providers should complete this item for every submission; a response of Yes may indicate the request is not medically necessary and could lead to denial under the form’s exclusions.

Coding Information

Administration CPT (provider-supplied)CPT

Administration code(s) (CPT)

Field on form for provider to supply administration CPT codes

ICD-10 Codes (provider-supplied)ICD-10

Primary ICD Code	Primary ICD diagnosis code — provider to supply
Secondary ICD Code	Secondary ICD diagnosis code — provider to supply
Other ICD Code	Other ICD diagnosis code — provider to supply

Provider Actions and Submission Requirements

Prior Authorization

Precertification Required

Prior authorization (precertification) is required for Dysport (abobotulinumtoxinA). Prior authorization must be requested from Aetna before services are rendered.

Contact Aetna Precertification: Phone 1-866-752-7021 (TTY:711); Fax 1-888-267-3277
Medicare Advantage Part B requests: use the Medicare request form
All fields on the precertification request form must be completed and legible
Start of treatment vs continuation of therapy must be indicated with dates

Documentation Required

Prior Conservative Therapy Documentation

Documentation of prior conservative therapy is required where applicable (e.g., chronic anal fissure, axillary hyperhidrosis, and other indications where first-line treatments exist). The request must indicate prior therapies tried, duration, response, and reasons for discontinuation or failure.

Chronic anal fissure: document trial and failure of topical calcium channel blockers or topical nitrates
Primary axillary hyperhidrosis: document trial of topical aluminum chloride/extra-strength antiperspirants and outcome
For other indications, provide prior conservative therapies attempted, dates, and clinical response

Documentation Required

Required Submission Documentation

Complete and legible completion of all form fields and supporting clinical information is required for precertification review. Include patient, insurance, prescriber, dispensing/administration, product, diagnosis, and detailed clinical information. For continuation requests, include evidence of therapeutic benefit.

Patient demographics: name, DOB, contact, weight, height, allergies
Insurance: Aetna Member ID, group number, other coverage and IDs, Medicare/Medicaid IDs if applicable
Prescriber: name, credentials, specialty, address, phone, NPI, state license
Dispensing/Administration: place of administration, administration CPT codes, dispensing provider/pharmacy details
Product: requested drug (Dysport), dose, frequency
Diagnosis: primary and secondary ICD-10 codes
Clinical Information: indication-specific checkboxes and narrative details; for initiation include specialist involvement when required
Continuation requests: documentation that treatment was effective

Denial Risk

Fraud Warning

Any person who knowingly submits materially false information or conceals material information on the authorization request may be subject to criminal and civil penalties. The plan may request additional information or clarification to evaluate requests.

Signature and date required on the acknowledgement section of the form
Fraudulent submission may result in criminal and civil penalties

Background

Dysport (abobotulinumtoxinA) is a botulinum toxin formulation used in this precertification form for multiple focal movement and related disorders. The form lists covered indications including blepharospasm, cervical dystonia, chronic anal fissure, excessive salivation (chronic sialorrhea), hemifacial spasm, and limb spasticity, and requests indication‑specific clinical information and prescriber specialty or consultation where applicable.

Definitions

Initiation vs Continuation — definitions and requirements

DefinitionInitiation = starting treatment with the requested drug; Continuation = ongoing therapy after prior treatment

Continuation requirementFor continuation requests, the form requires documentation that the requested drug was effective for treating the diagnosis (form asks 'Was the requested drug effective?' with Yes/No)

Date of last treatmentContinuation requests request the date of last treatment (form captures prior treatment timing as part of clinical information)

Form checkbox distinctionThe form includes separate clinical sections and checkboxes for 'For Initiation Requests' and 'For Continuation Requests' to distinguish the request type

Action for prescribersWhen requesting continuation, include documentation of prior benefit and relevant prior treatment details on the precertification form