Prior authorization validity

Initial prior authorization approvals are valid for 6 months (180 days) from the date of authorization; renewals may be issued every 12 months (365 days) thereafter.

Prior authorization recommended per NQTL checklist

Prior authorization should be considered for this drug based on the NQTL factors: indication, safety/efficacy, and drug cost; utilization review or prior authorization methods may be applied.

Use covered ICD-10 diagnosis code from Appendix 1

When requesting coverage or authorization, providers must bill using an ICD-10 diagnosis code listed in Appendix 1; one of these covered codes should be used to support medical necessity.

Required prior medication trials (examples)

Documented prior medication trials are required where indicated (example: for overactive bladder, member must have failed a ≥1 month trial of two medications from the antimuscarinic or beta-adrenergic classes).

Step therapy considerations per NQTL

Evaluation and documentation of prior treatment options may be considered in utilization management per the NQTL factor checklist; the policy notes consideration of prior therapies though no additional explicit multi-step algorithm is specified here.

Baseline disease severity assessment required for chronic migraine

For chronic migraine prophylaxis, the physician must document a baseline assessment of disease severity using an objective tool such as HIT-6, monthly headache days (MHD), MIDAS, or MPFID prior to treatment.

Billing and dosing documentation (HCPCS J0587 & NDCs)

Billing for rimabotulinumtoxinB must use HCPCS code J0587 (Injection, rimabotulinumtoxinB, 100 units; 1 billable unit = 100 units); NDCs for Myobloc single‑dose vials are listed in the policy and dosing/administration per indication should be documented with treatment claims.

• HCPCS: J0587 — Injection, rimabotulinumtoxinB, 100 units; 1 billable unit = 100 units
• NDCs: 10454-0710-xx; 10454-0711-xx; 10454-0712-xx
• Document dose administered and indication-specific dosing/retreatment interval with claim

Medicare Part B coverage and documentation requirements

For Medicare Part B claims, providers must follow applicable CMS guidance (Medicare Benefit Policy Manual, relevant NCDs/LCDs/LCAs); compliance with any applicable NCD/LCD/LCA is required when billing Medicare.

Contraindications and concurrent botulinum toxin therapy — denial risk

Requests may be denied if the member has FDA‑labeled contraindications (for example, hypersensitivity to any botulinum toxin product or active infection at the proposed injection site) or is receiving concurrent treatment with another botulinum toxin.

Prior authorization risk based on indication, safety/efficacy, and cost

Prior authorization may be applied because of concerns about indication appropriateness, safety/efficacy, and drug cost as identified in the NQTL factor checklist; utilization review or PA methods may therefore occur.

Dual coding requirement — claims denial risk

Claims using primary G and M diagnosis codes will require an accompanying secondary G or I code to be payable; failure to include the required secondary code may result in denial.

Document site of care per indication-specific dosing guidance

Site of administration is not specified in this excerpt; follow the indication-specific dosing and administration guidance in the policy when documenting site and procedure details for claims.