CurrentAetnaPolicy N/A

Daxxify (daxibotulinumtoxinA-lanm) Medication Precertification Request Form

This document is Aetna's medication precertification request form for Daxxify (daxibotulinumtoxinA-lanm), used by providers to request start or continuation of therapy and provide clinical, insurance, and administration details for coverage review.

Policy Summary

PayerAetna

PolicyDaxxify (daxibotulinumtoxinA-lanm) Medication Precertification Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed, signed precertification form including patient, prescriber, product, ICD codes, and required clinical details to support review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page

8form sections (A–H)

1-866-752-7021precert phone

1-888-267-3277precert fax

Coverage Criteria

Required clinical criteria for review

Form requests clinical items that support coverage determination; presence of these items does not guarantee approval but are required for review.

General requirements: Indicate whether therapy is prescribed for cosmetic purposes (e.g., treatment of wrinkles or uncorrected congenital strabismus with no binocular fusion); provide full clinical documentation; form must be completed and signed.

From 'For All requests' section

Initiation for cervical dystonia: Prior to initiating therapy with the requested drug, document abnormal placement of the head with limited range of motion in the neck AND whether the drug will be prescribed by or in consultation with a neurologist, orthopedist, or physiatrist.

From 'For Initiation Requests' section

Continuation: For continuation requests, document that the requested drug was effective for treating the diagnosis or condition.

Policy Summary

PayerAetna

PolicyDaxxify (daxibotulinumtoxinA-lanm) Medication Precertification Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed, signed precertification form including patient, prescriber, product, ICD codes, and required clinical details to support review.

SourceLink

On This Page

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Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Precertification is required for Daxxify (daxibotulinumtoxinA-lanm). The precertification form must indicate whether this is the start of treatment (include start date) or a continuation of therapy (include date of last treatment).

Precertification contact: Phone 1-866-752-7021 (TTY: 711); Fax 1-888-267-3277
For Medicare Advantage Part B: Use Medicare Request Form
Form must check one: Start of treatment (and provide start date) OR Continuation of therapy (and provide date of last treatment)

Documentation Required

Cervical Dystonia — Initiation Documentation Required

For initiation of treatment for cervical dystonia, the form must include specific clinical documentation demonstrating abnormal head placement with limited range of motion and that the prescriber is an appropriate specialist or consulted with one.

Document abnormal placement of the head with limited neck range of motion (yes/no) and describe findings
Document that the drug is prescribed by or in consultation with a neurologist, orthopedist, or physiatrist (check specialty and include prescriber specialty on form)

Documentation Required

Required Form Fields and Clinical Documentation

Providers must submit a fully completed precertification form including patient, prescriber, dispensing, product, administration, diagnosis, and clinical details. All required fields must be legible.

Patient demographics and contact information (name, DOB, address, phone, weight, height, allergies)
Prescriber information: name, credentials (MD/DO/NP/PA), address, phone, fax, state license #, NPI #, specialty (neurologist/orthopedist/physiatrist/other)
Dispensing/provider and administration details: place of administration, administration CPT code(s), dispensing provider/pharmacy name, address, phone, TIN
Product information: Daxxify, requested dose and frequency
Diagnosis: primary and any secondary ICD-10 codes
Clinical information: indication (cosmetic vs therapeutic), initiation vs continuation responses, effectiveness for continuation requests

Denial Risk

Incomplete or Insufficient Documentation

Incomplete or insufficient documentation may not be evaluated and can result in denial or request for additional information. The plan may request clarification or further records; failure to provide complete answers or required signatures can delay or prevent approval.

All fields must be completed and legible for precertification review
Signature and date required on the acknowledgement section
Incomplete forms may be returned or denied

Background

Daxxify (daxibotulinumtoxinA-lanm) is a botulinum toxin product included on this precertification form; the form captures common indications such as movement disorders (example: cervical dystonia/torticollis) and distinguishes between initiation and continuation of therapy. For initiation, the form requests condition-specific clinical details (for cervical dystonia: documentation of abnormal head placement with limited neck range of motion and confirmation that the drug will be prescribed by or in consultation with a neurologist, orthopedist, or physiatrist). For continuation requests, the form asks whether the requested drug was effective for treating the diagnosis or condition.

Initial Therapy Criteria

Initiation requirements

Initiation-specific clinical items required for certain indications (example: cervical dystonia).

Cervical dystonia initiation: Document abnormal placement of the head with limited range of motion in the neck.

Must be completed for initiation requests

Specialist prescribing/consultation: Document that the requested drug will be prescribed by or in consultation with a neurologist, orthopedist, or physiatrist.

Must be completed for initiation requests

Step	Indication	Required documentation	Prescriber/specialist requirement
1	Cervical dystonia (e.g., torticollis)	Documentation that, prior to initiating therapy, there is abnormal placement of the head with limited range of motion in the neck (form asks provider to indicate Yes/No).	The drug must be prescribed by or in consultation with a neurologist, orthopedist, or physiatrist (form asks provider to indicate Yes/No).

Primary ICD Code	Field for primary diagnosis ICD code
Secondary ICD Code	Field for secondary diagnosis ICD code
Other ICD Code	Field for other diagnosis ICD code(s)

OpenPayer

Daxxify (daxibotulinumtoxinA-lanm) Medication Precertification Request Form

Coverage Criteria

Coding

Provider Actions and Requirements

Definitions

Background

Initial Therapy Criteria

Continuation Therapy Criteria

Site of Care