CurrentClover HealthPolicy 5236-A

Jurisdiction Specific Medicare Part B Dysport

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Clover Health Medicare Part B coverage and prior authorization for Dysport (abobotulinumtoxinA), including covered indications, clinical criteria, exclusions, and treatment frequency in Kentucky and Ohio.

Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Dysport

Policy CodePolicy 5236-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor severe primary axillary hyperhidrosis, document inadequate management with topical therapy before requesting Dysport authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Listed covered indications

12 monthsAuthorization duration

2+ yearsMinimum age for spasticity

90 daysMinimum injection interval

2 sessionsTreatment failures affecting coverage

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CurrentClover HealthPolicy 5236-A

Jurisdiction Specific Medicare Part B Dysport

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Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Dysport

Policy CodePolicy 5236-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor severe primary axillary hyperhidrosis, document inadequate management with topical therapy before requesting Dysport authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Listed covered indications

12 monthsAuthorization duration

2+ yearsMinimum age for spasticity

90 daysMinimum injection interval

2 sessionsTreatment failures affecting coverage

KY, OHMedicare jurisdiction

Covered Indications and Exclusions

Cervical dystonia

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

Cervical dystonia: Member has cervical dystonia (spasmodic torticollis) and is an adult.Adult

Spasticity

Authorization may be granted for 12 months.

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

Blepharospasm

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

Blepharospasm: Member has blepharospasm and is an adult.Adult

Hemifacial spasm

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

Hemifacial spasm: Member has hemifacial spasm and is an adult.Adult

Achalasia

Authorization may be granted for 12 months when any of the following criteria are met.

Achalasia criteria

Member has not responded satisfactorily to conventional therapy.
Member is at high risk of complication from pneumatic dilation or surgical myotomy.
Member has had treatment failure with pneumatic dilation or surgical myotomy.
Member had perforation from pneumatic dilation.
Member has an epiphrenic diverticulum or hiatal hernia.
Member has esophageal varices.

Hyperhidrosis

Authorization may be granted for 12 months when all of the following criteria are met.

Severe primary axillary hyperhidrosis

Sweating characteristics
- Member has focal, visible, severe sweating of at least 6 months' duration without apparent cause.At least 6 months
- At least 2 of the following characteristics
  - Sweating is bilateral and relatively symmetric.
  - Sweating causes significant impairment in daily activities.
  - Age of onset was less than 25 years.

Treatment of wrinkles using botulinum toxins is considered cosmetic and is not covered.

Payment will not be made for spastic conditions of smooth muscle, including spastic colon and biliary dyskinesia.

Botulinum toxin injections for spastic or excess muscular contraction conditions given more frequently than every 90 days are generally not considered medically necessary.

Authorization and Frequency Requirements

Hyperhidrosis duration

Required durationAt least 6 months

Botulinum toxin injection interval

Minimum injection intervalNot more frequently than every 90 days

Prior Authorization and Documentation Guidance

Prior Authorization

Neurologic Indications

Prior authorization may be granted for 12 months for treatment of cervical dystonia (spasmodic torticollis) in an adult, spasticity in a member 2 years of age or older, blepharospasm in an adult, or hemifacial spasm when the applicable age and indication criteria are met.

Cervical dystonia: adult member.
Spasticity: member 2 years of age or older.
Blepharospasm: adult member.
Hemifacial spasm: when applicable indication criteria are met.

Prior Authorization

Achalasia and Hyperhidrosis

Prior authorization may be granted for 12 months for achalasia when at least one applicable criterion is met, or for severe primary axillary hyperhidrosis when all applicable criteria are met.

Achalasia: inadequate response to conventional therapy; high risk of complication from pneumatic dilation or surgical myotomy; treatment failure with pneumatic dilation or surgical myotomy; perforation from pneumatic dilation; epiphrenic diverticulum or hiatal hernia; or esophageal varices.

Clinical Terminology

Cervical dystonia

Cervical dystoniaSpasmodic torticollis

Initial Authorization Criteria

Cervical dystonia

Authorization of 12 months may be granted.

Cervical dystonia: Treatment is for cervical dystonia (spasmodic torticollis) in an adult.Adult

Spasticity

Authorization of 12 months may be granted.

Spasticity: Treatment is for spasticity in a member 2 years of age or older.Age 2 years and older

Blepharospasm or hemifacial spasm

Authorization of 12 months may be granted.

Continuation and Treatment Failure

Continuation after treatment failure

Continuation of therapy may be affected by repeated treatment failure.

Definitive treatment failure: Failure of two definitive, consecutive treatment sessions involving a muscle or group of muscles may preclude further coverage of the serotype used in the treatment for a period of one year after the second session.2 consecutive sessions; 1-year exclusion period

It may be reasonable to attempt treatment with a different serotype.

Required Prior Therapy

Step	Requirement
1	Before Dysport authorization, the member must be inadequately managed with topical therapy for severe primary axillary hyperhidrosis.

Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Dysport

Policy CodePolicy 5236-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor severe primary axillary hyperhidrosis, document inadequate management with topical therapy before requesting Dysport authorization.

SourceLink

On This Page

There is a positive family history.

Focal sweating ceases during sleep.

Topical therapy: Member is inadequately managed with topical therapy.Inadequate management

Hyperhidrosis: focal, visible, severe sweating for at least six months without apparent cause, with at least two specified characteristics, and inadequate management with topical therapy.

Step Therapy

Topical Therapy Requirement

For severe primary axillary hyperhidrosis, document inadequate management with topical therapy before requesting authorization.

The condition must also meet the policy criteria for severe primary axillary hyperhidrosis.

Unsupported block type: documentation

Denial Risk

Cosmetic Wrinkle Treatment Not Covered

Treatment of wrinkles using botulinum toxins is considered cosmetic and is not covered.

Do not submit cosmetic wrinkle treatment as a covered medical indication.

Denial Risk

Excluded Smooth-Muscle Conditions

Payment will not be made for spastic conditions of smooth muscle, including spastic colon and biliary dyskinesia.

Examples of excluded conditions include spastic colon and biliary dyskinesia.

Denial Risk

Repeated Treatment Failure

Failure of two definitive, consecutive treatment sessions involving a muscle or group of muscles could preclude further coverage of the serotype used for one year after the second session. A different serotype may be considered.

Document treatment response and the number of definitive consecutive sessions.
Coverage may be precluded for the serotype used after the second failed session.

Billing Rule

Treatment Frequency Limit

Botulinum toxin injections for spastic or excess muscular contraction conditions given more frequently than every 90 days are generally not considered medically necessary.

Generally maintain at least a 90-day interval between injections for these conditions.

Adult focal movement disorders: Treatment is for blepharospasm or hemifacial spasm in an adult.Adult

Achalasia

Authorization of 12 months may be granted when any of the following criteria are met.

Achalasia criteria

Member has not responded satisfactorily to conventional therapy.
Member is at high risk of complication from pneumatic dilation or surgical myotomy.
Member has had treatment failure with pneumatic dilation or surgical myotomy.
Member had perforation from pneumatic dilation.
Member has an epiphrenic diverticulum or hiatal hernia.
Member has esophageal varices.

Hyperhidrosis

Authorization of 12 months may be granted when all criteria are met.

Severe primary axillary hyperhidrosis

Member has focal, visible, severe sweating for at least 6 months without apparent cause.At least 6 months
At least 2 of the following characteristics
- Sweating is bilateral and relatively symmetric.
- Sweating causes significant impairment in daily activities.
- Age of onset was less than 25 years.
- There is a positive family history.
- Focal sweating ceases during sleep.
Member is inadequately managed with topical therapy.Inadequate management