CurrentCareSourcePolicy N/A

Botulinum Toxin - Xeomin (incobotulinumtoxinA) Utilization Management Medical Policy

Defines prior authorization, coverage criteria, dosing limits, and excluded uses for Xeomin (incobotulinumtoxinA) for medical benefit claims; applies to providers requesting coverage for affected indications.

Policy Summary

PayerCareSource

PolicyBotulinum Toxin - Xeomin (incobotulinumtoxinA) Utilization Management Medical Policy

Policy CodePolicy N/A

Change TypeAge requirement additions

Effective DateN/A

Next Review DateOct 2, 2024

Key ActionSubmit prior authorization requests for Xeomin for medical benefit coverage when patients meet the listed indication-specific criteria and dosing limits.

SourceLink

POLICY UPDATE CHANGES

Blepharospasm: An age requirement of ≥ 18 years was added and a clarifying note was added that includes blepharospasm associated with dystonia, benign essential blepharospasm, and seventh (VII) nerve disorders.

Cervical dystonia: an age requirement of ≥ 18 years was added.

Sialorrhea, chronic: an age requirement of ≥ 2 years was added.

Upper limb spasticity: an age requirement of ≥ 2 years was added.

4FDA-approved indication groups listed

100Blepharospasm max (total)

120Cervical dystonia max

400Upper limb spasticity max

Not recommendedCosmetic uses coverage

Coverage Criteria and Indications

Initial/Standard Therapy Criteria

Covered when ALL of the following are met for each indication as specified below:

Covered Indications - top level

Blepharospasm: Patient is ≥ 18 years of age; indication includes blepharospasm associated with dystonia, benign essential blepharospasm, or seventh (VII) nerve disorders; approve up to a maximum dose of 100 units (50 units per eye); administered not more frequently than once every 12 weeks.
Approve for 1 year.
Cervical dystonia: Patient is ≥ 18 years of age; (also known as spasmodic torticollis); approve up to a maximum dose of 120 units; administered not more frequently than once every 12 weeks.
Approve for 1 year.
Sialorrhea, chronic:

Policy Summary

PayerCareSource

PolicyBotulinum Toxin - Xeomin (incobotulinumtoxinA) Utilization Management Medical Policy

Policy CodePolicy N/A

Change TypeAge requirement additions

Effective DateN/A

Next Review DateOct 2, 2024

Key ActionSubmit prior authorization requests for Xeomin for medical benefit coverage when patients meet the listed indication-specific criteria and dosing limits.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Dosing Intervals and Maximum Dose Limits

Dosing interval for blepharospasm

Dosing intervalNot more frequently than once every 12 weeks

ContextBlepharospasm approvals are for patients ≥ 18 years of age (includes blepharospasm associated with dystonia, benign essential blepharospasm, and seventh (VII) nerve disorders).

Approval durationTypically approved for 1 year when criteria met.

Blepharospasm maximum dose

Maximum total dose100 units (50 units per eye)

Patient ageApplicable for patients ≥ 18 years of age

Approval durationTypically approved for 1 year when criteria met.

Cervical dystonia max dose and interval

Maximum total doseUp to 120 units

Dosing intervalNot more frequently than once every 12 weeks

Patient ageApplicable for patients ≥ 18 years of age

Sialorrhea max dose and interval (≥2 yrs)

Pediatric (≥2 years) and adult (<18 years) maximumUp to 100 units total (50 units per side)

Adult (≥18 years) maximumUp to 75 units total (37.5 units per side)

Dosing intervalNot more frequently than once every 16 weeks

Approval durationTypically approved for 1 year when criteria met.

Upper limb spasticity dosing limits

Adult weight‑based regimenUp to 16 units/kg, not to exceed 400 units

Absolute maximum regimenUp to 400 units (alternate entry)

Dosing intervalAdministered not more frequently than once every 12 weeks

Patient ageApplicable for patients ≥ 2 years of age (regimens differ by age).

Prior Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Recommended

Prior authorization is recommended for medical benefit coverage of Xeomin. Approvals are recommended for members who meet the indication-specific Criteria and Dosing in this policy. Approvals are provided for the durations noted in the policy (typically 1 year) and may be extended if the patient continues to meet the Criteria and Dosing. Requests for doses outside the established dosing documented in this policy will be reviewed on a case-by-case basis by a clinician (e.g., Medical Director or Pharmacist).

All approvals are for the duration specified in the policy (typically 1 year).
Prior authorization is recommended for medical benefit coverage.
Requests for doses outside established dosing will be reviewed on a case-by-case basis by a clinician.

Documentation Required

Provider Documentation

Providers should submit clinical documentation that demonstrates the patient meets the indication-specific criteria and dosing limits described in this policy when requesting prior authorization.

Include relevant diagnosis, prior therapies, dosing history, and rationale for treatment.
Document age and other indication-specific eligibility details per the dosing criteria.

Denial Risk

Coverage Exclusions and Denial Triggers

Coverage of Xeomin for cosmetic uses or for indications not listed in the Recommended Authorization Criteria is not recommended. Requests for these uses are likely to be denied.

Examples of cosmetic uses: facial rhytides, frown lines, glabellar wrinkling, horizontal neck rhytides, mid and lower face and neck rejuvenation, platysmal bands, periorbital rejuvenation.
Coverage is not recommended for any circumstances not listed in the Recommended Authorization Criteria; criteria will be updated as new published data are available.

OpenPayer

Botulinum Toxin - Xeomin (incobotulinumtoxinA) Utilization Management Medical Policy

Coverage Criteria and Indications

Dosing Intervals and Maximum Dose Limits

Prior Authorization, Documentation, and Denial Triggers

Background and Drug Information

Definitions and Drug Names