CurrentEmblemHealthPolicy N/A

Daxxify (daxibotulinumtoxinA-lanm) for cervical dystonia — Medical Benefit Prior Authorization

Medicare Advantage medical policy governing prior authorization and medical benefit coverage of Daxxify for adults with cervical dystonia; excludes cosmetic uses. Applies to specified Medicare Advantage lines of business and regions listed.

Policy Summary

PayerEmblemHealth

PolicyDaxxify (daxibotulinumtoxinA-lanm) for cervical dystonia — Medical Benefit Prior Authorization

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateOct 31, 2024

Next Review DateN/A

Key ActionObtain prior authorization and document that the patient meets criteria (age ≥18, cervical dystonia diagnosis, dose ≤250 units, interval ≥3 months).

SourceLink

POLICY UPDATE CHANGES

Daxxify was added to Local Coverage Article A52848.

The maximum dosing limitation was lowered from 300 to 250 units.

1 yearauthorization duration

≥18minimum age

250max approved dose

3 momin dosing interval

Recommended Authorization Criteria

Policy Summary

PayerEmblemHealth

PolicyDaxxify (daxibotulinumtoxinA-lanm) for cervical dystonia — Medical Benefit Prior Authorization

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateOct 31, 2024

Next Review DateN/A

Key ActionObtain prior authorization and document that the patient meets criteria (age ≥18, cervical dystonia diagnosis, dose ≤250 units, interval ≥3 months).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Cervical Dystonia

Covered when ALL of the following are met:

Cervical Dystonia Coverage Criteria

Patient is 18 years of age or older.age >= 18
Diagnosis of cervical dystonia (spasmodic torticollis).
Dosing does not exceed 250 units and administration is not more frequent than once every 3 months.dose <= 250 units; interval >= 3 months

The policy excludes Daxxify for cosmetic uses. Examples include facial rhytides, frown lines, glabellar wrinkling, horizontal neck rhytides, mid and lower face and neck rejuvenation, platysmal bands, and periorbital rejuvenation. These cosmetic indications are not recommended for coverage under the medical benefit.

Any circumstances not specifically listed in the Recommended Authorization Criteria are not recommended for approval. The policy will be updated if new published data expand or modify the covered indications.

Use of Daxxify for purely cosmetic indications is not medically necessary under the medical benefit and is not recommended for coverage.

Drug and Dosing Information

Referenced drugNDC|mixed

daxibotulinumtoxinA-lanm

Daxxify (drug name as listed)

inv-06: Maximum dose — numeric dosing limit

Maximum total dose per treatment250 units

Approval duration when criteria metApprove for 1 year

Related noteMaximum dosing limitation applies to cervical dystonia (spasmodic torticollis)

inv-07: Dosing interval — minimum time between doses

Minimum interval between treatmentsNot more frequently than once every 3 months

Dosing frequency implicationRepeat administrations must respect the 3-month minimum interval

Applies toCervical dystonia (spasmodic torticollis)

inv-08: Minimum age for coverage

Minimum age for coverage≥ 18 years

Approval durationApprove for 1 year when criteria met

IndicationCervical dystonia (spasmodic torticollis)

Authorization, Documentation, and Coverage Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for Daxxify medical benefit coverage. Approvals are provided for 1 year when the patient meets the policy Criteria and Dosing. Extended approvals may be granted if the patient continues to meet criteria and dosing requirements. In this policy, when dosing intervals are specified in months, 1 month = 30 days.

Approval duration: 1 year
Dosing interval note: 1 month = 30 days

Documentation Required

Documentation to Support Authorization

Submit documentation supporting the clinical indication and dosing that satisfies the Recommended Authorization Criteria (e.g., diagnosis of cervical dystonia, patient age ≥ 18 years, and dosing not more frequent than once every 3 months up to 250 units). Include prior treatment history if relevant and any objective findings that support medical necessity.

Denial Risk

Cosmetic Uses Excluded

Requests for cosmetic uses of Daxxify are not recommended for coverage and are subject to denial. Examples of cosmetic uses include facial rhytides, frown lines, glabellar wrinkling, horizontal neck rhytides, mid and lower face and neck rejuvenation, platsymal bands, and periorbital region rejuvenation.

Cosmetic uses: examples listed above are excluded from medical benefit coverage

Denial Risk

Criteria Not Met — Denial Risk

If the submitted information does not meet the policy Criteria and Dosing (for example, diagnosis other than a covered indication or dosing outside the approved parameters), the request may be denied. Coverage is limited to indications listed in the Recommended Authorization Criteria; other indications are not recommended unless new published data expand the criteria.

Denial risk when criteria or dosing not met
Coverage limited to listed Recommended Authorization Criteria

Note

Medicare Guidance and Coding Lists — Reference Only

Preserve and reference applicable Medicare NCDs, LCDs, companion articles, and coding lists when available; however, the presence or absence of a specific HCPCS or ICD-10 code alone does not automatically determine coverage. Use coding lists for reference only and provide supporting clinical documentation.

OpenPayer

Daxxify (daxibotulinumtoxinA-lanm) for cervical dystonia — Medical Benefit Prior Authorization

Recommended Authorization Criteria

Drug and Dosing Information

Authorization, Documentation, and Coverage Guidance

Drug Background

Key Definitions