Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesNeurology/NeurosurgeryAvMed botulinum toxin A Prior Auth Policy Update |…
    Ask Trek AI about this page
    CurrentAvMedPolicy Pub. 100-2

    Botulinum toxin type A injections (Botox, Xeomin) prior authorization

    Customize your policy alerts

    Sign up for AvMed Policy Pub. 100-2 alerts

    Get alerted when Policy Pub. 100-2 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This form and policy govern prior authorization and step-edit requests for medical use of botulinum toxin type A (onabotulinumtoxinA, incobotulinumtoxinA) for AvMed members, specifying clinical criteria, documentation, limits, and submission instructions for providers.

    Policy Summary
    PayerAvMed
    PolicyBotulinum toxin type A injections (Botox, Xeomin) prior authorization
    Policy CodePolicy Pub. 100-2
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionSubmit a completed, signed AvMed Medical Prior Authorization/Step-Edit Request form with required member/prescriber details, diagnosis and ICD code, dosing, weight, and supporting documentation; fax to 1-877-535-1391.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    400maximum cumulative dose for adults
    ≤10u/kg

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    pediatric max dose
    J0585,J0588HCPCS drug codes
    Multipledocumented indications

    Coverage and Medical Necessity Criteria

    Initial approval criteria (by indication)

    Covered when ALL of the following are met for the selected indication (each indication has specific subcriteria that must be satisfied and documented):

    General requirements: Provider submits completed, signed prior authorization form with required member and prescriber information, diagnosis, ICD code if applicable, dosing, and supporting documentation; documentation must support each checked clinical criterion.

    Cosmetic uses of botulinum toxin type A are explicitly excluded from coverage under this policy. Authorization requests for cosmetic indications will not meet medical necessity criteria and should not be submitted for prior authorization.

    Use of manufacturer samples or starter doses to initiate therapy does not satisfy the step-edit or prior authorization initiation requirements. Requests relying on samples as evidence of prior therapy failure or tolerability will be considered insufficient for approval.

    Coding, Dose Limits, and Billing

    Covered HCPCS codes (drugs listed on form)HCPCSCovered
    J0585Botox (onabotulinumtoxinA)
    J0588Xeomin (incobotulinumtoxinA)
    Maximum cumulative adult dose
    Maximum cumulative adult dose400 units per 3-month interval
    ApplicabilityApplies to adult patients treated for one or more indications; cumulative across indications
    Limit periodMeasured over a 3-month (quarterly) interval
    Pediatric maximum dose
    Pediatric maximum doseLower of 10 units/kg body weight or 340 units per 3-month interval
    Dose calculationUse patient's body weight to calculate 10 units/kg when determining the lower limit
    Limit periodMeasured over a 3-month (quarterly) interval
    Adult maximum dose (definition)
    Adult maximum cumulative dose (definition)Maximum cumulative dose for adults: 400 units in a 3-month period
    ContextApplies across one or more indications for adult patients
    Policy noteExceeding this limit may affect authorization decisions
    Pediatric maximum dose (definition)
    Pediatric maximum cumulative dose (definition)Pediatric maximum dose: the lower of 10 units/kg body weight or 340 units in a 3-month interval
    Calculation requirementProvider must document patient weight to verify the 10 units/kg threshold
    Limit periodMeasured over a 3-month (quarterly) interval

    Prior Authorization, Submission, and Documentation Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required. Submit the AvMed Medical Prior Authorization/Step-Edit Request form signed by the prescribing physician (preprinted signature stamps are not valid). Fax the completed form to 1-877-535-1391. If information provided is not complete, correct, or legible, authorization may be delayed or denied. For urgent reviews, contact AvMed Pre-Authorization Department if a standard review would subject the member to adverse health consequences.

    • Form must be signed by prescribing physician (handwritten signature; preprinted stamps not valid).
    • Fax completed form to 1-877-535-1391.
    • For Medicare members, comply with Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 and any applicable NCDs/LCDs.
    Documentation Required

    Required Submission Information

    Provide complete member and prescriber information on the request form. Authorization may be delayed if fields are incomplete or illegible.

    Clinical Background

    Botulinum toxin type A preparations (e.g., onabotulinumtoxinA, incobotulinumtoxinA) are used for a range of neurologic and non‑neurologic indications, including spasticity, dystonia, blepharospasm and other facial/spasm disorders, select gastrointestinal sphincter conditions, and bladder dysfunction such as neurogenic detrusor overactivity. Clinical response and documentation of prior conservative or indicated therapies are required for many indications; dosing limits apply, with a maximum cumulative adult dose of 400 units per 3‑month interval and pediatric dosing limited to the lower of 10 units/kg or 340 units per 3‑month interval.

    Policy Summary
    PayerAvMed
    PolicyBotulinum toxin type A injections (Botox, Xeomin) prior authorization
    Policy CodePolicy Pub. 100-2
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionSubmit a completed, signed AvMed Medical Prior Authorization/Step-Edit Request form with required member/prescriber details, diagnosis and ICD code, dosing, weight, and supporting documentation; fax to 1-877-535-1391.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaCoding, Dose Limits, and BillingPrior Authorization, Submission, and Documentation RequirementsClinical Background
    • Member name, AvMed member number, and date of birth.
    • Prescriber name, DEA or NPI number, office contact name, phone and fax numbers.
    • Prescriber signature and date (signature required).
    Denial Risk

    Documentation and Prior Therapy Verification

    Include all clinical documentation and evidence of prior therapies as applicable. Use of samples to initiate therapy does not satisfy step-edit or prior authorization requirements. Previous therapies will be verified via pharmacy paid claims or submitted chart notes; chart notes must document therapy failures as required by clinical criteria.

    • Clinical criteria checklist must be completed and supported by chart notes, lab results, diagnostics, and/or urodynamic testing when indicated.
    • Document trials and failures of prior medications (duration and agents used).
    • Samples do not meet initiation or step-therapy requirements; they will not be accepted as proof of prior therapy.