CurrentCareSourcePolicy N/A

Dysport (abobotulinumtoxinA) — Arkansas PASSE Pharmacy Coverage Criteria

Defines prior authorization, coverage criteria, dosing limits, and renewal requirements for Dysport (abobotulinumtoxinA) for cervical dystonia and spasticity for CareSource members in Arkansas PASSE benefit type.

Policy Summary

PayerCareSource

PolicyDysport (abobotulinumtoxinA) — Arkansas PASSE Pharmacy Coverage Criteria

Policy CodePolicy N/A

Change TypeDosing and criteria revisions

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document indication and dosing limits; for reauthorization include chart notes demonstrating clinical improvement compared to baseline.

SourceLink

POLICY UPDATE CHANGES

Removed age and specialist requirement for cervical dystonia.

Clarified renewal criteria for cervical dystonia to focus on symptoms rather than quality of life wording.

Updated dosing limits and authorization durations for spasticity and cervical dystonia across prior versions.

1000Cervical dystonia max/12wk

1500Spasticity adult max/12wk

1000 or 30/kgPediatric spasticity max/3mo

6 moInitial approval

12 moReauthorization (cervical dystonia)

Coverage Criteria for Dysport (abobotulinumtoxinA)

Cervical Dystonia — Initial Therapy

Covered when ALL of the following are met

Cervical Dystonia initial criteria: Member has a documented diagnosis of moderate to severe cervical dystonia.

Cervical Dystonia dosing/limit: Dosage allowed/Quantity limit: Up to 1000 units every 12 weeks, divided among affected muscles.1000 units/12 weeks

If all the above requirements are met; the medication will be approved for 6 months.

Cervical Dystonia — Reauthorization

Covered when ALL of the following are met

Cervical dystonia reauth:

Policy Summary

PayerCareSource

PolicyDysport (abobotulinumtoxinA) — Arkansas PASSE Pharmacy Coverage Criteria

Policy CodePolicy N/A

Change TypeDosing and criteria revisions

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document indication and dosing limits; for reauthorization include chart notes demonstrating clinical improvement compared to baseline.

SourceLink

On This Page

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Chart notes must show improved severity, disability, or pain compared to baseline.

If all the above requirements are met; the medication will be approved for an additional 12 months.

Spasticity — Initial Therapy

Covered when ALL of the following are met

Age requirement: Member is at least 2 years of age.

Diagnosis impact: Member has a documented diagnosis of upper or lower limb spasticity that affects daily functioning and quality of life.

Specialist involvement: Medication is prescribed by or in consultation with a neurologist or other specialist experienced with treating spasticity (e.g., PM&R).

Etiology: Spasticity is secondary to a neurologic condition such as cerebral palsy, stroke, or brain or spinal cord injury.

Conventional treatment trial: Member has tried or is unable to try one conventional treatment modality such as physical therapy or oral medication (e.g., baclofen, tizanidine).

Dosing/quantity limits: Dosage allowed/Quantity limit: Adult: Not to exceed 1500 total units every 12 weeks (divided among affected muscles); Pediatric: Not to exceed 1000 total units or 30 units per kg (whichever is lower) every 3 months.adult 1500 units/12 weeks; pediatric 1000 units or 30 units/kg/3 months

If all the above requirements are met; the medication will be approved for 6 months.

General Not Medically Necessary

Excluded diagnoses: Dysport is considered not medically necessary for diseases not listed in this document; diagnoses such as blepharospasm and upper extremity dystonia (e.g., writer's cramp) are not covered.

Requests for Dysport for diagnoses that are not listed in this policy are considered not medically necessary. Examples specifically noted as no longer covered include blepharospasm and upper extremity dystonia (e.g., writer's cramp). Providers should not expect authorization for these indications.

CareSource considers Dysport (abobotulinumtoxinA) not medically necessary for the treatment of diseases not listed in this document. Historically excluded diagnoses include blepharospasm and upper extremity dystonia (writer's cramp), which are no longer covered under this policy.

Initial Therapy Criteria and Dosing Limits

Initial therapy — Initial authorization criteria and dosing limits

Initial authorization criteria and dosing limits

Cervical dystonia init: Documented diagnosis of moderate to severe cervical dystonia.1000 units/12 weeks

If all the above requirements are met; the medication will be approved for 6 months.

Spasticity init: Age >= 2 years; documented upper or lower limb spasticity affecting daily functioning and quality of life; medication prescribed by or in consultation with a neurologist or specialist experienced with treating spasticity; spasticity secondary to a neurologic condition (e.g., cerebral palsy, stroke, brain or spinal cord injury); trial of or inability to try one conventional treatment modality (e.g., physical therapy or oral medication such as baclofen or tizanidine); dosing limits — adult not to exceed 1500 total units every 12 weeks, pediatric not to exceed 1000 total units or 30 units/kg (whichever is lower) every 3 months.adult 1500 units/12 weeks; pediatric 1000 units or 30 units/kg/3 months

If all the above requirements are met; the medication will be approved for 6 months.

Reauthorization / Continuation Criteria

Reauthorization — Reauthorization requirements

Reauthorization requirements

Cervical dystonia continuation: Chart notes must show improved severity, disability, or pain compared to baseline for reauthorization.

If met, approved for 12 months.

Spasticity continuation: Chart notes must show improved signs and symptoms (e.g., decrease in severity of increased muscle tone) compared to baseline for reauthorization.

If met, approved for an additional 12 months.

Dosing Limits and Coding Notes

Pediatric spasticity dosing — Dysport

Pediatric spasticity dosing limitNot to exceed 1000 total units or 30 units per kg every 3 months (whichever is lower)

Applicable agePatients 2 years of age and older (policy specifies spasticity treatment in patients >=2 years)

Authorization intervalQuantity limit evaluated every 3 months (per policy: every 3 months for pediatric dosing)

Adult dosing limits

Cervical dystonia (adult) dosing limitUp to 1000 units every 12 weeks

Spasticity (adult) dosing limitNot to exceed 1500 total units every 12 weeks

Authorization duration when criteria metIf requirements met, approved for 6 months (initial)

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Dysport (abobotulinumtoxinA). Approval is granted only when the specific indication criteria, dosing limits, and documentation requirements are met.

Benefit type: Medical
Status: Prior Authorization Required
Dosage/Quantity limits applied per indication (see criteria)

Step Therapy

Conventional Treatment Trial Required for Spasticity

For spasticity requests, the member must have tried or be unable to try at least one conventional treatment modality (for example, physical therapy or an appropriate oral antispasticity medication such as baclofen or tizanidine) unless clinically contraindicated or not feasible.

Applies to upper or lower limb spasticity affecting daily functioning and quality of life
Specialist involvement required (prescribed by or in consultation with neurologist or PM&R)

Documentation Required

Reauthorization — Document Clinical Improvement

For reauthorization, chart notes must document clinical improvement from baseline: for cervical dystonia this may include improved severity, disability, pain, or abnormal head position; for spasticity this must show improved signs and symptoms (for example, decreased muscle tone or functional improvement).

Cervical dystonia: improvement in severity, disability, or pain compared to baseline
Spasticity: documentation of improved signs and symptoms (e.g., decreased increased muscle tone)

Denial Risk

Excluded Indications — Not Medically Necessary

Requests for Dysport for diagnoses not listed in this policy (for example, blepharospasm, upper extremity dystonia/writer's cramp) are considered not medically necessary and will be denied.

Examples of excluded indications: blepharospasm; upper extremity dystonia (e.g., writer's cramp)
If diagnosis is not among listed covered indications (cervical dystonia, spasticity), request is not covered

Step Therapy Requirements

Step	Requirement
1	Member must have tried at least one conventional treatment modality (e.g., physical therapy or an oral medication such as baclofen or tizanidine), or be unable to try such a modality.

Quantity Limits and Maximum Dosage

Dysport (abobotulinumtoxinA) — Up to 1000 units

Quantity limit (Dysport)Up to 1000 units

Per intervalPer policy: up to 1000 units every 12 weeks for cervical dystonia

IndicationReferenced for cervical dystonia dosing limits in adults

Dysport (abobotulinumtoxinA) — Adult maximum

Adult maximum (spasticity)Not to exceed 1500 total units every 12 weeks

Dosing contextDivided among affected muscles and given intramuscularly

Authorization intervalEvaluated every 12 weeks for adults

Dysport (abobotulinumtoxinA) — Pediatric maximum

Pediatric maximum (spasticity)Not to exceed 1000 total units or 30 units/kg every 3 months (whichever is lower)

Applicable agePatients 2 years of age and older (policy indicates spasticity treatment applies from age 2)

Dosing intervalEvery 3 months (quarterly)

Definitions

Cervical dystonia — definition

DefinitionCervical dystonia (spasmodic torticollis): involuntary contractions of the neck causing abnormal movements and postures of the neck and head.

Clinical effectCauses abnormal movements and postures of the neck and head due to involuntary neck contractions

SynonymAlso known as spasmodic torticollis

Background

Dysport (abobotulinumtoxinA) is a botulinum neurotoxin type A agent that produces muscle relaxation by inhibiting acetylcholine release at peripheral nerve endings. It is addressed in this policy for specified indications (cervical dystonia and spasticity); treatments and reauthorizations are governed by the criteria and dosing limits set forth herein.

Revision History

2025-04-01policy_effectiveLatest

Policy effective date updated to 2025-04-01 (current effective date).

2024-10-02material_change

Removed age and specialist requirement for cervical dystonia.

2023-11-14clarification

Cervical dystonia: removed 'Symptoms affect quality of life and daily functions' language and clarified renewal criteria.

2022-03-04annual_review

Annual review completed with no changes.

2021-08-10format_update

Policy transferred to new template and allowing additional specialists for cervical dystonia and spasticity indications.

2020-08-17policy_revision

Cervical dystonia: added age limit and specialist requirement, reworded diagnosis requirement, removed trial of oral medication, corrected dose, extended reauthorization duration; Spasticity: added age and specialist requirements, updated to match label, added trial of conventional treatment and extended initial authorization duration.

2018-08-06new_policy

New policy created; diagnoses of blepharospasm and upper extremity dystonia (e.g., writer's cramp) were designated as no longer covered.