CurrentClover HealthPolicy 6354-A

Jurisdiction Specific Medicare Part B Daxxify

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This policy governs prior authorization and coverage of Daxxify under Medicare Part B for adults with cervical dystonia, subject to approval criteria and exclusions.

Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Daxxify

Policy CodePolicy 6354-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization for adult cervical dystonia treatment with Daxxify; approval may be granted for 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered indication listed

12 monthsMaximum authorization duration stated

AdultsEligible population

CosmeticExplicitly excluded use

Lowest effective doseDosing principle

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CurrentClover HealthPolicy 6354-A

Jurisdiction Specific Medicare Part B Daxxify

Customize your policy alerts

Sign up for clover_health Policy 6354-A alerts

Get alerted when Policy 6354-A changes without checking for updates manually.

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This policy governs prior authorization and coverage of Daxxify under Medicare Part B for adults with cervical dystonia, subject to approval criteria and exclusions.

Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Daxxify

Policy CodePolicy 6354-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization for adult cervical dystonia treatment with Daxxify; approval may be granted for 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered indication listed

12 monthsMaximum authorization duration stated

AdultsEligible population

CosmeticExplicitly excluded use

Lowest effective doseDosing principle

Covered and Excluded Uses

Cervical dystonia

Covered when the following criterion is met:

Adult cervical dystonia: Member is an adult with cervical dystonia

Authorization may be granted for 12 months

Cosmetic use of Daxxify is excluded from coverage. Coverage will not be provided when Daxxify is prescribed for cosmetic use.

Authorization and Documentation Requirements

Prior Authorization

Adult Cervical Dystonia Authorization

Authorization for 12 months may be granted when Daxxify is used to treat cervical dystonia in adults.

Documentation Required

Evidence for Other Indications

Indications other than cervical dystonia are assessed on an individual basis. Submissions for other indications must include supporting evidence from Medicare-approved compendia.

Denial Risk

Cosmetic Use Excluded

Coverage will not be provided when Daxxify is prescribed for cosmetic use.

Initial Authorization

Initial authorization

Authorization may be granted when the following criterion is met:

Adult patient with cervical dystonia: Patient is an adult with cervical dystonia

Authorization duration is 12 months

Policy Summary

PayerClover Health

PolicyJurisdiction Specific Medicare Part B Daxxify

Policy CodePolicy 6354-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization for adult cervical dystonia treatment with Daxxify; approval may be granted for 12 months.

SourceLink

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