CurrentCareSourcePolicy N/A

Daxxify (daxibotulinumtoxinA-lanm) for Cervical Dystonia

Defines medical benefit coverage and prior authorization criteria for Daxxify (daxibotulinumtoxinA-lanm) in adults with cervical dystonia; excludes cosmetic uses.

Policy Summary

PayerCareSource

PolicyDaxxify (daxibotulinumtoxinA-lanm) for Cervical Dystonia

Policy CodePolicy N/A

Change TypeAnnual revision

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and document ongoing clinical response and dosing intervals to support initial or extended approval per the policy criteria.

SourceLink

POLICY UPDATE CHANGES

New policy created and reviewed 08/30/2023; annual revision reviewed 09/25/2024.

250maximum single dose approved

3minimum dosing interval (months)

12initial approval duration (months)

Medical Necessity Criteria

Medically Necessary / FDA-Approved Indication

Coverage of Daxxify is recommended when ALL of the following are met:

ALL of the following

Indication is cervical dystonia (also known as spasmodic torticollis).
Patient is 18 years of age or older.>= 18 years

Dosing and Duration Limits

Approvals follow these dosing constraints:

ALL of the following

Policy Summary

PayerCareSource

PolicyDaxxify (daxibotulinumtoxinA-lanm) for Cervical Dystonia

Policy CodePolicy N/A

Change TypeAnnual revision

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and document ongoing clinical response and dosing intervals to support initial or extended approval per the policy criteria.

SourceLink

On This Page

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Not Recommended / Exclusions

Coverage is not recommended in the following situations:

ANY of the following

Cosmetic uses are excluded from medical benefit coverage.
Examples: facial rhytides, frown lines, glabellar wrinkling, horizontal neck rhytides, mid and lower face and neck rejuvenation, platysmal bands, periorbital region rejuvenation.
Indications not listed in the Recommended Authorization Criteria.

What Providers Must Do

Prior Authorization

Prior Authorization Recommended

Prior Authorization is recommended for medical benefit coverage of Daxxify. Approval is recommended for patients who meet the Criteria and Dosing specified; requests for doses outside the policy dosing will be reviewed case-by-case by a clinician.

Affected product codes: daxibotulinumtoxinA-lanm

Documentation Required

Support for Extended Approvals — Document Ongoing Response

Extended approvals are allowed if the patient continues to meet the Criteria and Dosing; providers should document ongoing clinical response and dosing intervals to support extension.

Affected product codes: daxibotulinumtoxinA-lanm

Denial Risk

Cosmetic Use Denial Risk

Requests for cosmetic indications will be denied/not recommended because cosmetic use is excluded from medical benefit coverage.

Affected product codes: daxibotulinumtoxinA-lanm
Examples of excluded cosmetic uses: facial rhytides, frown lines, glabellar wrinkling, horizontal neck rhytides, mid and lower face and neck rejuvenation, platysmal bands, periorbital region rejuvenation

Clinical Background

Daxxify (daxibotulinumtoxinA-lanm) is an acetylcholine release inhibitor and neuromuscular blocking agent indicated for the treatment of cervical dystonia (also known as spasmodic torticollis) in adults. Prior Authorization is recommended for medical benefit coverage; when approved for this FDA‑approved indication, dosing is limited to a maximum single dose of 250 units and administrations should occur not more frequently than once every 3 months. Initial approvals are provided for 1 year, and extended approvals may be granted if the patient continues to meet the criteria and dosing requirements.

OpenPayer

Daxxify (daxibotulinumtoxinA-lanm) for Cervical Dystonia

Medical Necessity Criteria

Product / Drug Codes

What Providers Must Do

Key Numeric and Clinical Thresholds

Clinical Background

Defined Terms

Policy Changes