CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Botulinum Toxin Injectable Request Form — Coverage Criteria

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Form and criteria for requesting outpatient botulinum toxin (e.g., Botox, Dysport) under the medical benefit for Highmark BlueShield NENY members; used by ordering providers and facilities to document clinical information for authorization decisions.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Botulinum Toxin Injectable Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed Outpatient Medical Injectables Botulinum Toxin Request Form with indication-specific documentation and selected J-code for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4clinical sections on form

4listed HCPCS J-codes

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CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Botulinum Toxin Injectable Request Form — Coverage Criteria

Customize your policy alerts

Sign up for all Highmark Blueshield Neny policy alerts

Know when Highmark Blueshield Neny releases new policies or updates existing guidance.

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Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Botulinum Toxin Injectable Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed Outpatient Medical Injectables Botulinum Toxin Request Form with indication-specific documentation and selected J-code for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4clinical sections on form

4listed HCPCS J-codes

Coverage Criteria for Botulinum Toxin Injections

Chronic Migraine

Chronic migraine - covered when ALL of the following are met

Chronic migraine initiation/continuation criteria: Member meets ICHD-III diagnostic criteria for chronic migraine and has a documented persistent three-month history of recurring debilitating headaches recorded in a headache diary or calendar; request is prescribed by or in consultation with a neurologist or headache specialist; administration will be performed by a healthcare provider trained in botulinum toxin injection; member has tried and failed adequate trials of prophylactic therapy from at least two different therapy classes (e.g., antiseizure, beta blocker, tricyclic antidepressant) with adequate dose and duration (e.g., ~6 weeks each); for continuation: documented >=50% reduction in headache frequency and/or >=50% reduction in headache hours from baseline after starting botulinum toxin.>=50% reduction in frequency and/or hours for continuation

Exclude headaches due to medication rebound or lifestyle issues until addressed.

Hyperhidrosis

Hyperhidrosis - covered when ALL of the following are met

Hyperhidrosis criteria: Member has severe focal hyperhidrosis in specified region(s) (eg axillary, palmar, plantar, craniofacial, other); history of recurrent skin maceration with bacterial or fungal infections and/or history of atopic dermatitis despite medical treatments is assessed; member has failed or is intolerant to topical antiperspirants (eg 20% aluminum chloride) and to pharmacotherapy modalities prescribed for excessive sweating (eg anticholinergics); for continuation: documented objective measurable improvement (eg improvement in Hyperhidrosis Disease Severity Scale [HDSS]) after botulinum toxin treatment.objective improvement (eg HDSS)

Form documents focal region, prior therapies, skin history, and objective response for continuation.

Other Uses / General

Other indications - covered when ALL of the following are met

Other uses criteria: Provider lists all other therapies tried and failed, not tolerated, or contraindicated for the diagnosis; for continuation: there is documented positive clinical response to prior botulinum toxin treatment as recorded on the form.documented positive clinical response

Form requires listing prior therapies and documenting response for other uses.

Headaches that are clearly attributable to medication overuse (rebound) or to identifiable lifestyle causes are captured on the chronic migraine section of the request form and do not meet the chronic migraine coverage criteria unless those issues are addressed. The form explicitly asks whether headaches are caused by medication rebound or lifestyle issues, and an affirmative response indicates the underlying cause must be managed before the request will satisfy the policy’s chronic migraine criteria.

Requests are at risk for denial when the submitted documentation does not include required prior-therapy trials or lacks objective evidence of response for continuation. For chronic migraine, the form requires documentation of trials and failures of adequate prophylactic therapy from at least two different classes (examples: antiseizure, beta blocker, tricyclic antidepressant) with verification that each was given at an adequate dose and reasonable duration (e.g., ~6 weeks each). For hyperhidrosis, the form requires evidence of failure or intolerance of topical antiperspirants (for example, 20% aluminum chloride) and appropriate pharmacotherapy. Continuation requests must document objective benefit — for chronic migraine this is a documented ≥ 50% reduction in headache frequency and/or hours from baseline, and for hyperhidrosis an objective measurable improvement (for example, improvement in HDSS).

Coding and Response Thresholds

Listed botulinum toxin HCPCS J-codesHCPCS

J0585	BOTOX
J0586	DYSPORT
J0587	MYOBLOC
J0588	XEOMIN

inv-07: Migraine response threshold — >= 50% reduction in headache frequency and/or hours from baseline

Response threshold>= 50% reduction in headache frequency and/or hours from baseline

Documentation requiredThree-month headache diary or calendar documenting persistent recurring debilitating headaches

Diagnosis standardDiagnosis established using ICHD-III (International Classification of Headache Disorders, Third Edition)

Prescriber/administratorTreatment prescribed by or in consultation with a neurologist/headache specialist and administered by a provider trained in botulinum toxin injection

Prior therapy requirementTrials and failures of adequate prophylactic therapy from at least two different classes (e.g., antiseizure, beta blocker, tricyclic antidepressant) with adequate dose/duration (e.g., ~6 weeks each)

Provider Actions and Prior Authorization Requirements

Prior Authorization

Form-based prior authorization required

Prior authorization requires submission of the completed Outpatient Medical Injectables Botulinum Toxin Request Form with indication‑specific information and selection of the J‑code for the requested botulinum product.

Form must be fully completed and faxed as the prior authorization request.

Step Therapy

Document required prior therapy trials before approval

For chronic migraine, the form must document trials and failures of at least two different prophylactic therapy classes (for example antiseizure, beta blocker, tricyclic antidepressant); for hyperhidrosis, failure or intolerance of topical antiperspirants and pharmacotherapy should be documented.

Chronic migraine: list all previous prophylactic therapies tried and failed and confirm adequate dose/duration (example ~6 weeks each).
Hyperhidrosis: document unresponsiveness or intolerance to pharmacotherapy (eg anticholinergics) and topical 20% aluminum chloride or other extra‑strength antiperspirants.

Background

Botulinum toxin injections are used for multiple outpatient indications captured on the request form, including chronic migraine and focal hyperhidrosis, as well as other off‑label or less common uses. The purpose of the Outpatient Medical Injectables Botulinum Toxin Request Form is to collect standardized clinical information to support prior authorization decisions: member demographics and benefit verification, indication and ICD-10 diagnosis, the selected botulinum product J-code, provider and facility identifiers, detailed indication‑specific history (for example a three‑month headache diary and ICHD‑III confirmation for chronic migraine, focal region and prior topical/systemic therapy history for hyperhidrosis), and documentation of prior therapies and objective response when applicable. This information enables reviewers to determine whether initiation or continuation of botulinum toxin meets the policy’s coverage criteria.

Definitions and Response Measures

inv-15: Chronic migraine definition — reference to ICHD-III criteria and documentation expectations

Diagnostic criteriaDiagnosis must be established using the International Classification of Headache Disorders, Third Edition (ICHD-III)

Required documentationThree-month headache diary/calendar showing persistent recurring debilitating headaches

Treatment teamPrescribed by or in consultation with a neurologist/headache specialist; administered by a provider trained in botulinum toxin injection

Exclusions to assessHeadaches clearly due to medication rebound or lifestyle issues must be identified and addressed — such cases do not meet chronic migraine criteria

Continuation evidenceFor continuation requests, documentation must show objective response (>=50% reduction in frequency and/or hours) after starting botulinum toxin