CurrentAlaska MedicaidPolicy N/A

Botulinum toxin (Botox) prior authorization — multiple indications

Form and criteria governing prior authorization requests for botulinum toxin (Botox) for Alaska Medicaid members across multiple indications (e.g., chronic migraine, spasticity, hyperhidrosis, dystonias, bladder conditions). Affects prescribers, physician-administered drug billing, and pharmacy requests to Alaska Medicaid.

Policy Summary

PayerAlaska Medicaid

PolicyBotulinum toxin (Botox) prior authorization — multiple indications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form to the correct HMS or pharmacy fax and include required documentation (procedure codes, date of service, ICD-10, and supporting clinical notes).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥12indications listed

2physician fax contacts

2 trialsbladder trial req

≥2 classesmigraine trial req

Coverage Criteria by Indication

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Axillary Hyperhidrosis

Axillary Hyperhidrosis covered when ALL of the following are met

Axillary Hyperhidrosis: Topical agents are not controlling the condition.

Axillary Hyperhidrosis: Hyperhidrosis Disease Severity Scale (HDSS) score > 3.HDSM > 3

Blepharospasm

Blepharospasm covered when ALL of the following are met

Blepharospasm: Member is unable to open eyelid(s) or is functionally blind due to dystonia.

Blepharospasm: Ordering provider is a neurologist or ophthalmologist; if not, submit plan of care and chart notes from the ordering MD.

Cervical Dystonia

Cervical Dystonia covered when ALL of the following are met

Cervical Dystonia: Purpose of treatment is to reduce the severity of abnormal head position and neck pain.

Chronic Migraine

Chronic Migraine covered when ALL of the following are met

Chronic Migraine Initial: Patient has headaches ≥ 15 days per month lasting ≥ 4 hours per day.>=15 days/month

Chronic Migraine Initial: Trial with inadequate response, intolerance, or contraindication to at least 2 migraine prophylaxis classes (e.g., anticonvulsants, beta blockers).>=2 prophylaxis classes tried

Chronic Migraine Initial: Ordering provider is a neurologist; if not, submit plan of care and chart notes from the ordering MD.

Chronic Migraine Renewal: Headache frequency decreased by at least 2 headache days from baseline in the previous month (renewal criterion).

Chronic Sialorrhea

Chronic Sialorrhea covered when ALL of the following are met

Chronic Sialorrhea: Patient tried and failed one first-line agent (benztropine, oral hyoscyamine, or glycopyrrolate) or has a contraindication to all of them.1 failed agent or contraindication

Neurogenic Detrusor Overactivity

Neurogenic Detrusor Overactivity (NDO) covered when ALL of the following are met

Neurogenic Detrusor Overactivity: Documented symptoms of detrusor overactivity.

Neurogenic Detrusor Overactivity: Trial of 2 different pharmacologic treatments for at least 60 days with documentation of inadequate response or a justifiable contraindication to oral antimuscarinics or oral β3-adrenergic receptor agonists (e.g., oxybutynin, tolterodine, mirabegron).2 trials x >=60 days

Examples: oxybutynin, tolterodine, mirabegron

Overactive Bladder

Overactive Bladder covered when ALL of the following are met

Overactive Bladder: Documented moderate to severe symptoms of urge urinary incontinence, urgency, and frequency.

Overactive Bladder: Documented behavioral therapy trials.

Overactive Bladder: Trial of 2 different pharmacologic treatments for at least 60 days with documentation of inadequate response or a justifiable contraindication to oral antimuscarinics or oral β3-adrenergic receptor agonists (e.g., oxybutynin, tolterodine, mirabegron).2 trials x >=60 days

Spasticity / Upper Limb Spasticity

Spasticity covered when ALL of the following are met

Spasticity General: Spasticity is refractory to oral medication.

Upper Limb Spasticity (Cerebral Palsy): Spasticity secondary to cerebral palsy (form asks to confirm) and refractory to oral medication.

Form asks if spasticity is secondary to cerebral palsy; question defaults to 'No' for CP on the upper-limb specific section

Urinary Incontinence Secondary to Detrusor Overactivity

Urinary Incontinence Secondary to Detrusor Overactivity covered when ALL of the following are met

Urinary Incontinence (Secondary): Documented symptoms of detrusor overactivity.

Urinary Incontinence (Secondary): Trial of 2 different pharmacologic treatments for at least 60 days with documentation of inadequate response or a justifiable contraindication to oral antimuscarinics or oral β3-adrenergic receptor agonists (e.g., oxybutynin, tolterodine, mirabegron).2 trials x >=60 days

For any request to use botulinum toxin for an indication that is not an FDA‑approved use (non‑cosmetic), the form requires submission of supporting medical literature and a letter of medical necessity that documents the diagnosis and prior therapies. This additional documentation is necessary to allow clinical review of non‑FDA‑approved indications and must be attached to the prior authorization request.

Incomplete or missing additional documentation for non‑FDA‑approved indications will delay or prevent authorization; ensure the literature and letter explicitly describe the prior treatments tried and the rationale for botulinum toxin in this specific patient.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required. Complete and fax the Alaska Medicaid Botox® Prior Authorization Form to the appropriate recipient based on provider type: physician providers (office supply/J‑code billing) fax to HMS at (907) 644-8131; pharmacy providers fax to (888) 603-7696. This authorization request does not ensure eligibility or guarantee payment. Verify member Medicaid eligibility before submitting.

Fax numbers: HMS (907) 644-8131 — physicians (J‑code); Pharmacy: (888) 603-7696
Form available on Alaska Medicaid's Medication Prior Authorization website

Step Therapy

Bladder/Urinary Step Therapy Requirements

Step therapy for bladder/urinary indications requires documentation of prior trials. For Neurogenic Detrusor Overactivity and Overactive Bladder, patient must have tried two different pharmacologic treatments for at least 60 days with documentation of inadequate response or a justifiable contraindication to oral antimuscarinics or oral β3‑adrenergic receptor agonists (examples: oxybutynin, tolterodine, mirabegron). For Overactive Bladder, documented behavioral therapy trials are also required and symptoms must be moderate to severe.

Two pharmacologic trials required — duration: at least 60 days each
Acceptable agents include oral antimuscarinics or oral β3‑adrenergic agonists (e.g., oxybutynin, tolterodine, mirabegron)
Behavioral therapy documentation required for Overactive Bladder
Document presence of moderate to severe urge urinary incontinence, urgency, and frequency for Overactive Bladder requests

Documentation Required

Required Documentation and Attachments

Required documentation and attachments must accompany the prior authorization form. Physician requests must include procedure codes, date of service, and ICD‑10 diagnosis codes. Attach supporting documentation such as treatment history (dates and outcomes of prior pharmacologic therapies), behavioral therapy records when applicable, clinical notes describing symptoms, and any Letters of Medical Necessity or supporting literature.

Procedure codes and date of service (required for physician/J‑code billing)
ICD‑10 diagnosis code(s)
Documentation of prior pharmacologic trials (agents used, start/stop dates, reason for discontinuation or inadequate response)
Behavioral therapy documentation when applicable (for Overactive Bladder)
Letters of Medical Necessity or supporting clinical literature, if applicable

Denial Risk

Incomplete Request Denial Risk

Incomplete requests will be denied until all required information is received. Ensure all required fields on the form are completed (including prescriber and pharmacy information, drug name/NDC/strength, dosage, quantity/day supply, and attestation with prescriber signature and date).

Complete prescriber information (name, NPI, specialty, phone, fax, group ID)
Complete pharmacy information when pharmacy provider (pharmacy name, NPI, phone, fax, NDC, strength, dosage, quantity, day supply)
Include attestation with prescriber signature and date
Incomplete requests will be denied

NDC	NDC field present for pharmacy-dispensed product
Procedure Code	Procedure Code field required for physician providers (J-code billing)
ICD-10	ICD-10 diagnosis code field required

OpenPayer

Botulinum toxin (Botox) prior authorization — multiple indications

Coverage Criteria by Indication

Billing and Coding Requirements

What Providers Must Do

Background

Definitions and Non-standard Uses