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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsClover Health Dysport Coverage Policy | OpenPayer
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    CurrentClover HealthPolicy 2164-A

    Jurisdiction Specific Medicare Part B Dysport

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    This policy governs coverage and prior authorization for Dysport (abobotulinumtoxinA) under Medicare Part B for Clover Health members in Florida, Puerto Rico, and the U.S. Virgin Islands. It defines covered indications, age requirements, authorization duration, and exclusions.

    Policy Summary
    PayerClover Health
    PolicyJurisdiction Specific Medicare Part B Dysport
    Policy CodePolicy 2164-A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit supporting evidence from Medicare-approved compendia for indications other than the five listed covered uses.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    5listed covered indications
    12 monthsauthorization period
    Age 2+minimum age for spasticity treatment
    Cosmetic useexplicitly excluded use
    FL, PR, VI

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    policy jurisdiction

    Covered Indications and Exclusions

    Cervical Dystonia

    Authorization may be granted for 12 months when the member is an adult being treated for cervical dystonia.

    Cervical dystonia criteria: Member has cervical dystonia and is an adult.Adult

    Authorization duration is 12 months.

    Spasticity

    Authorization may be granted for 12 months when the member is 2 years of age or older and is being treated for spasticity.

    Spasticity criteria: Member has spasticity and is 2 years of age or older.Age 2 years or older

    Authorization duration is 12 months.

    Blepharospasm

    Authorization may be granted for 12 months when the member is an adult being treated for blepharospasm.

    Blepharospasm criteria: Member has blepharospasm and is an adult.Adult

    Authorization duration is 12 months.

    Hemifacial Spasm

    Authorization may be granted for 12 months when the member is an adult with hemifacial spasm.

    Hemifacial spasm criteria: Member has hemifacial spasm, a cranial nerve VII disorder, and is an adult.Adult

    Authorization duration is 12 months.

    Isolated Oromandibular Dystonia

    Authorization may be granted for 12 months when the member is an adult being treated for isolated oromandibular dystonia.

    Isolated oromandibular dystonia criteria: Member has isolated oromandibular dystonia and is an adult.Adult

    Authorization duration is 12 months.

    Coverage will not be provided when Dysport is used for cosmetic purposes.

    Authorization and Documentation Requirements

    Prior Authorization

    Adult Cervical Dystonia

    Authorization of 12 months may be granted for the treatment of cervical dystonia in adults.

    Prior Authorization

    Spasticity: Age 2 and Older

    Authorization of 12 months may be granted for the treatment of spasticity in members 2 years of age and older.

    Prior Authorization

    Adult Blepharospasm

    Authorization of 12 months may be granted for the treatment of blepharospasm in adults.

    Prior Authorization

    Adult Hemifacial Spasm

    Initial Authorization Criteria

    Cervical Dystonia

    Authorization may be granted for 12 months.

    Initial cervical dystonia therapy: Treatment of cervical dystonia in an adult.Adult

    Authorization duration is 12 months.

    Spasticity

    Authorization may be granted for 12 months.

    Initial spasticity therapy: Treatment of spasticity in a member 2 years of age or older.Age 2 years or older

    Authorization duration is 12 months.

    Blepharospasm

    Policy Summary
    PayerClover Health
    PolicyJurisdiction Specific Medicare Part B Dysport
    Policy CodePolicy 2164-A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit supporting evidence from Medicare-approved compendia for indications other than the five listed covered uses.
    SourceLink
    On This Page
    Covered Indications and ExclusionsAuthorization and Documentation RequirementsInitial Authorization Criteria

    Authorization of 12 months may be granted for hemifacial spasm in adults, including hemifacial spasm associated with a cranial nerve VII disorder.

    Prior Authorization

    Adult Isolated Oromandibular Dystonia

    Authorization of 12 months may be granted for the treatment of isolated oromandibular dystonia in adults.

    Documentation Required

    Supporting Evidence for Other Indications

    All indications other than the listed covered uses will be assessed on an individual basis. Submit supporting clinical evidence with requests for these other indications.

    • Document the clinical rationale and supporting evidence for the requested indication.
    Denial Risk

    Cosmetic Use Excluded

    Coverage will not be provided for cosmetic use of Dysport.

    • Cosmetic Dysport use is excluded from coverage.
    Documentation Required

    Unlisted Indications Require Compendia Support

    Requests for unlisted indications must be accompanied by supporting evidence from Medicare-approved compendia and will be reviewed individually.

    • Include documentation from Medicare-approved compendia when submitting an indication not listed as covered.

    Authorization may be granted for 12 months.

    Initial blepharospasm therapy: Treatment of blepharospasm in an adult.Adult

    Authorization duration is 12 months.

    Hemifacial Spasm

    Authorization may be granted for 12 months.

    Initial hemifacial spasm therapy: Treatment of hemifacial spasm, a cranial nerve VII disorder, in an adult.Adult

    Authorization duration is 12 months.

    Isolated Oromandibular Dystonia

    Authorization may be granted for 12 months.

    Initial isolated oromandibular dystonia therapy: Treatment of isolated oromandibular dystonia in an adult.Adult

    Authorization duration is 12 months.