DaxibotulinumtoxinA-lanm (Daxxify) (PDF)
Defines medical necessity, clinical criteria, dosing limits, approvals durations, and coding for Daxxify (daxibotulinumtoxinA-lanm) for commercial, HIM, and Medicaid lines of business, with specific criteria for cervical dystonia and exclusions for cosmetic and non‑FDA indications.
Added HCPCS code J0589 and removed C9399 and J3590.
Added step therapy bypass for IL HIM per IL HB 5395.
4Q 2024 annual review: no significant changes; references reviewed and updated.