Prior authorization required; preferred‑product requirement

Prior authorization is required for botulinum toxin therapies and requests will be reviewed for medical necessity. The policy requires that patients must have had an inadequate response, intolerable adverse event, or contraindication to ALL preferred products (Botox, Daxxify, Xeomin) for an FDA‑approved indication before Myobloc or Dysport will be approved, OR the member must already be receiving and benefiting from the requested targeted product through insurance.

• Prior authorization requests are reviewed for medical necessity.
• Targeted products (Myobloc, Dysport) require failure of all preferred products or ongoing documented benefit for approval.

Indication‑specific prior authorization and durations

Prior authorization is required and will be granted for the listed indications only when ALL criteria for that indication are met; typical authorizations are for 12 months (chronic migraine: 6 months/ two injection cycles).

• Indication‑specific criteria must be documented and met for approval.
• Chronic migraine authorization may be granted for 6 months (two injection cycles) when criteria are met.

Oromandibular dystonia — prior authorization

Authorization of 12 months may be granted for treatment of oromandibular dystonia when the indication‑specific criteria are met.

Myofascial pain syndrome — required prior treatments

Authorization of 12 months may be granted for myofascial pain syndrome only after documentation the member has tried and failed all of the following: physical therapy; injection of local anesthetics into trigger points; injection of corticosteroids into trigger points.

• Document trials of physical therapy, local anesthetic trigger‑point injections, and corticosteroid trigger‑point injections as failed before approval.

Focal hand dystonia — prior authorization

Authorization of 12 months may be granted for focal hand dystonia when the indication‑specific criteria are met.

Facial myokymia — prior authorization

Authorization of 12 months may be granted for facial myokymia when the indication‑specific criteria are met.

Hirschsprung disease — prior authorization and prior therapy requirement

Authorization of 12 months may be granted for Hirschsprung disease with internal sphincter achalasia only after endorectal pull‑through and when the member is refractory to laxative therapy; document prior therapies and refractory status.

• Require documentation member underwent endorectal pull‑through and is refractory to laxative therapy.

Orofacial tardive dyskinesia — prior therapy required

Authorization of 12 months may be granted for orofacial tardive dyskinesia only after conventional therapies (e.g., benzodiazepines, clozapine, tetrabenazine) have been tried and failed.

• Document trials and failures of conventional therapies prior to approval.

Painful bruxism — prior therapy required

Authorization of 12 months may be granted for painful bruxism when the member has had an inadequate response to a night guard and pharmacologic therapy (e.g., diazepam); document these prior trials.

• Document trial and failure of a night guard and pharmacologic therapy such as diazepam.

Palatal myoclonus — prior therapy required

Authorization of 12 months may be granted for palatal myoclonus when disabling symptoms persist after inadequate response to clonazepam, lamotrigine, carbamazepine, or valproate; document prior medication trials.

• Document inadequate response to listed anticonvulsant/benzodiazepine agents before approval.

First bite syndrome — prior therapy required

Authorization of 12 months may be granted for first bite syndrome when analgesics, antidepressants, or anticonvulsants have failed; document prior therapies.

• Document failure of analgesics, antidepressants, or anticonvulsants prior to approval.

Cervical dystonia (Myobloc) — age and clinical documentation

For Myobloc, authorization of 12 months may be granted for cervical dystonia in adults when member is ≥18 years and has abnormal head placement with limited neck range of motion.

• Document member age (≥18) and clinical features of cervical dystonia.

Chronic sialorrhea (Myobloc) — prior therapy and age documentation

For Myobloc, authorization of 12 months may be granted for chronic sialorrhea in adults refractory to pharmacotherapy (e.g., anticholinergics); document age and prior pharmacotherapy failure.

• Document member age (≥18) and failure of pharmacologic therapy such as anticholinergics.

Primary hyperhidrosis (Myobloc) — prior therapy documentation required

For Myobloc, authorization of 12 months may be granted for primary axillary or palmar hyperhidrosis when significant social/professional disruption is documented and topical aluminum chloride or extra‑strength antiperspirants are ineffective or cause severe rash.

• Document significant disruption and trial/failure or intolerance (severe rash) to topical antiperspirants.

Upper limb spasticity (Myobloc) — prior authorization

Authorization of 12 months may be granted for upper limb spasticity with Myobloc when the indication‑specific criteria are met; document diagnosis consistent with limb spasticity.

• Document primary diagnosis of upper limb spasticity or spasticity as a symptom of an underlying condition.

Cervical dystonia (Dysport) — age and clinical documentation

For Dysport, authorization of 12 months may be granted for cervical dystonia in adults when member is ≥18 years and has abnormal head placement with limited neck range of motion.

• Document member age (≥18) and abnormal head placement with limited neck ROM.

Limb spasticity (Dysport) — age and diagnosis documentation

For Dysport, authorization of 12 months may be granted for limb spasticity when the member is ≥2 years of age and has a primary diagnosis of upper or lower limb spasticity (including cerebral palsy‑related equinus gait); document age and diagnosis.

• Document member age (≥2 years) and primary diagnosis of limb spasticity or related condition.

Blepharospasm (Dysport) — prior authorization

For Dysport, authorization of 12 months may be granted for blepharospasm when indication criteria are met.

Hemifacial spasm (Dysport) — prior authorization

For Dysport, authorization of 12 months may be granted for hemifacial spasm when indication criteria are met.

Chronic anal fissures (Dysport) — prior therapy required

For Dysport, authorization of 12 months may be granted for chronic anal fissures only when the member has not responded to first‑line therapy such as topical calcium channel blockers or topical nitrates; document prior topical therapy failure.

• Document failure of first‑line topical therapies (calcium channel blockers or nitrates) prior to approval.

Prior authorization required for covered indications (typical 12‑month approvals)

Prior authorization of up to 12 months may be granted for covered indications when the listed clinical criteria are met; HCPCS/J‑codes for products are listed in the policy.

• See indication‑specific sections for exact clinical criteria and required documentation.
• Typical authorization duration is 12 months unless otherwise stated (e.g., chronic migraine).

Prior Authorization — policy history only (no new PA rules)

This section contains policy history and effective dates and does not specify additional prior authorization coding or criteria beyond the clinical rules already listed.

• Policy history and dates do not add new prior authorization requirements.

Step/Preferred product requirement for targeted products

Patient must have had inadequate response, intolerable adverse event, or contraindication to ALL preferred products (Botox, Daxxify, Xeomin) for an FDA‑approved indication before Myobloc or Dysport will be approved; alternatively, ongoing documented benefit on the requested product is an alternative pathway.

• Failure/intolerance/contraindication to all preferred products is required for targeted product approval.
• Continuation on requested product with documented benefit is acceptable in place of failing preferred products.

Required prior/conservative therapy — per indication

Many indications require failure of conservative measures or trials of specified medication classes prior to approval. Examples include chronic migraine (two oral preventative classes, each ≥60 days), overactive bladder (behavioral therapy plus two agents from anticholinergic or beta‑3 classes), and neurogenic urinary incontinence (behavioral therapy plus one agent).

• Chronic migraine: trials of two oral preventive classes with each trial ≥60 days.
• Overactive bladder: failed behavioral therapy plus inadequate response/intolerance to two agents from anticholinergic or beta‑3 agonist classes.
• Neurogenic urinary incontinence: failed behavioral therapy plus inadequate response/intolerance to one agent from anticholinergic or beta‑3 agonist classes.

Myofascial pain syndrome — step requirements

Myofascial pain syndrome authorization requires documented failure of all three: physical therapy; injection of local anesthetics into trigger points; and injection of corticosteroids into trigger points.

• All three conservative/injection therapies must have been attempted and documented as failed prior to approval.

Hyperhidrosis — required topical antiperspirant trial

Primary hyperhidrosis authorization requires documentation that topical aluminum chloride or other extra‑strength antiperspirants were ineffective or caused severe rash before approval.

• Document trial and failure or severe rash from topical antiperspirants prior to approval.

Painful bruxism — step requirements

Painful bruxism requires documentation of inadequate response to a night guard and pharmacologic therapy (e.g., diazepam) before authorization will be granted.

• Document failure of night guard and pharmacologic therapy prior to approval.

Step requirements for select indications (anal fissures, sialorrhea)

For select indications (e.g., chronic anal fissures, excessive salivation), member must have failed first‑line topical therapies or pharmacotherapy (e.g., topical calcium channel blockers or nitrates for anal fissures; anticholinergics for sialorrhea) before approval.

• Chronic anal fissures: document failure of topical calcium channel blockers or topical nitrates.
• Excessive salivation: document refractoriness to pharmacotherapy such as anticholinergics.

References and history — no step therapy rules included here

Reference and policy history sections contain literature references and do not include step‑therapy rules or additional authorization criteria.

• References provided for clinical support; no step therapy rules are defined in the reference/history chunks.

Prescriber specialty or documented consultation required

Prescriber specialty must be the listed specialty or there must be documented consultation with an appropriate specialist per indication (examples: neurologist, ophthalmologist, urologist, dermatologist, gastroenterologist).

• Ensure prescription is from an approved specialty or include documented specialist consultation.
• Match prescriber specialty to the indication per the policy's prescriber specialty list.

Required supporting documentation (age, diagnosis, prior therapy, specialist involvement)

Required supporting documentation must include member age, primary diagnosis, documentation of prior conservative or pharmacologic therapy trials (including durations where specified), and specialist involvement when required.

• Document member age and diagnosis.
• Provide records of prior therapy trials and durations (e.g., migraine preventive trials ≥60 days each).
• Include documentation of specialist consultation or prescriber specialty when required.

Hyperhidrosis prior therapy documentation required

For primary hyperhidrosis, include documentation that topical aluminum chloride or other extra‑strength antiperspirants were ineffective or caused severe rash.

• Include details of antiperspirant trial and outcome (ineffective or severe rash).

Dysport — age and diagnosis documentation required for limb spasticity

For Dysport treatment of limb spasticity, document member age (≥2 years) and primary diagnosis of upper or lower limb spasticity or related condition (including equinus gait due to cerebral palsy) as part of the prior‑authorization submission.

• Include member age (≥2 years) and primary diagnosis supporting limb spasticity.

Dosing limits and documentation — follow FDA labeling/compendia/guidelines

Approvals may be subject to dosing limits in accordance with FDA‑approved labeling, accepted compendia, and evidence‑based practice guidelines; include dosing documentation as applicable.

• Document intended dosing and ensure it aligns with FDA labeling, compendia, or guidelines.
• Approvals may be limited by the policy's quantity limits.

Clinical references listed — no documentation forms specified

References provided in the policy support clinical criteria and background; no documentation forms are specified in the references section.

• Clinical references are listed for support; they do not prescribe documentation formats.

Denial risk — preferred‑product exception required for targeted products

Requests for targeted products (Myobloc, Dysport) may be denied unless the patient has had inadequate response, intolerance, or contraindication to ALL preferred products (Botox, Daxxify, Xeomin) or is currently receiving and benefiting from the requested targeted product via insurance.

• Preferred‑product exception is required for approval of targeted products.
• Ongoing documented benefit on the requested product is an alternative to failing preferred products.

Denial risk — insufficient clinical criteria/documentation

Requests lacking documentation that required eligibility criteria are met (age minimums, prior therapy trials and durations, failure of required conservative therapies, or prescriber specialty/consultation) may be denied as insufficient clinical criteria.

• Insufficient documentation of age, diagnosis, prior therapy trials (and durations) or prescriber specialty risks denial.
• Failure to document required conservative therapies (e.g., PT, trigger‑point injections) risks denial.

Denial risk — myofascial pain syndrome prior treatments not met

Claims may be denied for myofascial pain syndrome if the member has not tried and failed the required prior treatments (physical therapy; local anesthetic trigger‑point injections; corticosteroid trigger‑point injections).

• Document and verify failure of all three required prior treatments before submission.

Denial risk — Hirschsprung disease prior therapy not met

Claims may be denied for Hirschsprung disease with internal sphincter achalasia if the member is not refractory to laxative therapy following endorectal pull‑through.

• Ensure documentation that member is refractory to laxative therapy after endorectal pull‑through to avoid denial.

Denial risk — orofacial tardive dyskinesia prior therapies not met

Claims may be denied for orofacial tardive dyskinesia if conventional therapies (e.g., benzodiazepines, clozapine, tetrabenazine) have not been tried and failed.

• Document trials and failures of conventional therapies before submission.

Denial risk — requests not meeting criteria are not medically necessary

Requests for Botox, Daxxify, Dysport, Myobloc, and Xeomin are considered not medically necessary and may be denied when members do not meet the criteria set forth in the policy.

• Therapies listed are not medically necessary without meeting policy criteria.

No authorization/denial criteria in reference/history sections

The reference/history sections contain literature citations only and do not include explicit authorization or denial criteria.

• References supply clinical support; they do not define additional authorization rules.