CurrentCignaPolicy IP0509

Botulinum Toxins - Myobloc

Defines Cigna coverage, prior authorization, criteria, dosing, and coding for Myobloc (rimabotulinumtoxinB) for cervical dystonia, chronic sialorrhea, and upper-limb spasticity in adults.

Policy Summary

PayerCigna

PolicyBotulinum Toxins - Myobloc

Policy CodePolicy IP0509

Change TypeCriteria and dosing revisions

Effective Date

Next Review Date

Key ActionObtain prior authorization and provide documentation of diagnosis and required clinical findings for approval.

SourceLink

POLICY UPDATE CHANGES

Cervical dystonia criteria updated to require age ≥18, documentation of diagnosis, documentation of head torsion with limited ROM, and specialty prescribing/consultation; dosing maximum reduced from 10,000 units to 5,000 units every 12 weeks.

Chronic sialorrhea and limb spasticity criteria updated to screen for age only.

CPT codes for relevant chemodenervation procedures (64611, 64616, 64642-64647) added to Coding Information.

Policy title updated from 'RimabotulinumtoxinB' to 'Botulinum Toxins - Myobloc'.

3covered indications listed

5,000 unitscervical dystonia max

3,500 unitssialorrhea max

20,000 unitsupper-limb spasticity max

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Coverage Criteria

Cervical Dystonia

Approve for 1 year if the patient meets ALL of the following (A, B, C, and D):

Cervical Dystonia Approval Criteria: A) Patient is ≥ 18 years of age; AND B) Patient has a diagnosis of cervical dystonia [documentation required]; AND C) Patient has sustained head torsion and/or tilt with limited range of motion in the neck [documentation required]; AND D) Prescribed by or in consultation with a pain medicine specialist, neurologist, or physical medicine and rehabilitation physiciandose: up to 5,000 units, interval: ≥ 12 weeks

Approve for 1 year

Chronic Sialorrhea

Approve for 1 year if the patient meets the following:

Chronic Sialorrhea Approval Criteria: Patient is ≥ 18 years of agedose: up to 3,500 units (1,750 units per side), interval: ≥ 12 weeks

Approve for 1 year

Spasticity, Upper Limb(s)

Approve for 1 year if the patient meets the following:

Upper-Limb Spasticity Approval Criteria: Patient is ≥ 18 years of agedose: up to 20,000 units, interval: ≥ 3 months

Supported by AAN Level B evidence for adult upper-limb spasticity

Coverage excludes cosmetic use of Myobloc (rimabotulinumtoxinB). Examples of excluded cosmetic uses listed in the policy include facial rhytides, frown lines, glabellar wrinkling, horizontal neck rhytides, mid and lower face and neck rejuvenation, platysmal bands, and rejuvenation of the periorbital region.

Use of Myobloc for any indication other than the listed covered or supported indications (cervical dystonia, chronic sialorrhea, and upper‑limb spasticity) is considered not medically necessary / not covered under the medical benefit.

Prior Authorization is required for benefit coverage, and requests for indications outside those specified in the policy will be managed as not medically necessary unless otherwise reviewed and approved per the prior authorization process.

Coding and Dosing Information

inv-09: Cervical dystonia dosing interval and max

Maximum doseUp to 5,000 units per dose

Minimum intervalNot more frequently than every 12 weeks

Approval durationApprove for 1 year when criteria met

inv-10: Chronic sialorrhea dosing interval and max

Maximum doseUp to 3,500 units per dose (1,750 units per side)

Minimum intervalNot more frequently than every 12 weeks

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization is required for benefit coverage of Myobloc. Approvals are recommended for patients who meet the listed criteria and dosing. Extended approvals are allowed if the patient continues to meet the Criteria and Dosing. Requests for doses outside the established dosing documented in this policy will be considered on a case-by-case basis by a clinician (e.g., Medical Director or Pharmacist). All approvals are provided for the duration noted in the policy. In cases where the dosing interval is provided in months, 1 month is equal to 30 days.

Policy: IP0509 — Prior authorization required
Approvals recommended when Criteria and Dosing are met; extended approvals allowed
Dose exceptions reviewed case-by-case by a clinician

Note

Provider Action / Alert

Providers should ensure prior authorization requests include the clinical information and documentation noted in the policy criteria (for example: diagnosis of cervical dystonia, documentation of sustained head torsion/tilt with limited range of motion, and specialty involvement when required).

Background

Myobloc (rimabotulinumtoxinB) is a botulinum toxin type B neuromuscular blocking agent. The policy notes that Myobloc has FDA‑approved indications for cervical dystonia and chronic sialorrhea in adults, and it is also supported by evidence for use in adult upper‑limb spasticity.

Per the policy, prior authorization is required for Myobloc; approvals are recommended for patients who meet the specified clinical criteria and dosing limits and are typically granted for a duration of 1 year. Documentation is required where noted in the criteria (for example, diagnosis of cervical dystonia and documentation of sustained head torsion with limited range of motion).

Definitions

inv-17: Definition for cervical dystonia (spasmodic torticollis)

DefinitionCervical dystonia (spasmodic torticollis) – sustained head torsion and/or tilt with limited neck range of motion.

Alternate nameSpasmodic torticollis

DocumentationDocumentation of sustained head torsion and/or tilt with limited neck range of motion is required for approval