CurrentHighmark Blueshield NenyPolicy N/A

Botulinum toxin prior authorization — chronic migraine, hyperhidrosis, and other uses

Governs prior authorization information and clinical questions required for medical benefit administration of botulinum toxin for chronic migraine, hyperhidrosis, and other uses for Highmark BlueShield regions. Affects ordering providers, administering facilities, and specialty pharmacies submitting requests.

Policy Summary

PayerHighmark Blueshield Neny

PolicyBotulinum toxin prior authorization — chronic migraine, hyperhidrosis, and other uses

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form including ICD-10 diagnosis, drug J-code, dose/units, frequency, number of visits, and indication-specific supporting documentation (eg headache diary for chronic migraine).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Named indication sections

4Listed HCPCS/J-codes

2Response types

Coverage Criteria for Botulinum Toxin

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Chronic migraine coverage criteria: 1) Diagnosis of chronic migraine established using the International Classification of Headache Disorders, Third Edition (ICHD-III); 2) Persistent three-month history of recurrent debilitating headache documented by the member via headache diary or calendar; 3) Headache frequency and duration responses provided (days per month and hours per episode); 4) Request prescribed by or in consultation with a neurologist or headache specialist; 5) Administration by a healthcare provider trained in botulinum toxin (Botox) administration; 6) Prior trials and failures of adequate prophylactic therapy from at least two different therapy classes (e.g., antiseizure, beta blocker, tricyclic antidepressant) with adequate dose/duration; 7) For continuation of therapy, objective clinical response since starting botulinum toxin defined as ≥50% reduction in migraine frequency or ≥50% reduction in migraine hours from baseline.>=50% reduction for continuation response

Form requests fields to document each element

Hyperhidrosis

Covered when ALL of the following are met

Hyperhidrosis coverage criteria: 1) Severe focal hyperhidrosis present and the treatment region specified (axillary, palmar, plantar, craniofacial, or other); 2) History of failed or intolerant topical therapy (e.g., 20% aluminum chloride or extra-strength antiperspirants) and/or systemic pharmacotherapy for excessive sweating (e.g., anticholinergics, beta-blockers, benzodiazepines); 3) Documentation of recurrent skin maceration with bacterial or fungal infections or refractory atopic dermatitis despite medical treatments when applicable; 4) For continuation of therapy, documented objective measurable improvement in response to treatment (e.g., improvement in HDSS).objective measurable improvement (eg HDSS)

Form asks to describe improvement

Other Indications

Covered when ALL of the following are met

Other indications coverage criteria: 1) List of all therapies tried and failed, not tolerated, or contraindicated for the diagnosis provided on the form; 2) For continuation of therapy, documentation of a documented positive clinical response to treatment; 3) Attach supporting documentation as requested on the form (e.g., clinical notes, outcome measures).

Form provides fields to capture prior therapies and response

Requests for botulinum toxin for chronic migraine are excluded when headaches are attributable to reversible causes such as medication rebound or identifiable lifestyle issues rather than true chronic migraine. The prior authorization form explicitly asks whether headaches are caused by medication rebound or lifestyle factors; an affirmative response indicates the condition may not meet chronic migraine criteria and should be addressed before considering coverage for chronic migraine treatment.

A request may be considered incomplete or may be denied if the submission lacks documentation of required prior therapy trials, specialist involvement when requested, or the member’s treatment history. Specifically, the form requires documentation that the diagnosis meets ICHD-III criteria, confirmation of a persistent three-month headache diary/calendar history, and evidence of trials and failures of at least two prophylactic therapy classes. In addition, if the form indicates that a neurologist or headache specialist prescribed or was consulted, supporting documentation should be included; absence of a trained administrator or missing treatment details (drug, dose, duration, and response) can also render the request incomplete.

Provider Actions, Documentation & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for botulinum toxin injections. Submit a completed prior authorization request form that includes the requested drug (name and HCPCS/J‑code), dose/units, frequency, number of visits, diagnosis (ICD‑10 code(s)), requested start date, and indication‑specific fields. Requests must be submitted prior to initiation of treatment per payer requirements.

Include drug name and HCPCS/J‑code (e.g., BOTOX J0585; DYSPORT J0586; MYOBLOC J0587; XEOMIN J0588)
Dose / number of units and frequency
Number of visits requested
ICD‑10 diagnosis code(s) and requested start date
Provider and member identifiers (member name, DOB, member ID/UMI), ordering/attending provider name, NPI, office contact, phone, fax, servicing facility name and NPI

Denial Risk

Chronic Migraine Documentation — Denial Risk

For chronic migraine, the prior authorization form must document a persistent 3‑month history of recurring debilitating headaches and include objective documentation such as a headache diary or calendar. Failure to provide the 3‑month headache history, headache diary/calendar, or documentation of prior prophylactic therapy trials (including doses and duration) may result in denial.

Number of headache days per month, average duration in hours, and duration of the chronic pattern
Confirm diagnosis per ICHD‑III (yes/no) and whether managed by or in consultation with a neurologist/headache specialist
Documentation of a 3‑month headache history via diary/calendar is required
List of prior prophylactic therapies tried from at least two different classes (e.g., antiseizure, beta‑blocker, tricyclic antidepressant), with reason for failure, intolerance, or contraindication and whether prescribed at adequate dose/duration (example benchmark: ~6 weeks)

Documentation Required

Required Form Fields & Attachments

The completed prior authorization form must include member and provider identifiers, ICD‑10 code(s), requested start date, the specific drug and HCPCS/J‑code, dose/units, frequency, number of visits requested, and any applicable attachments (evidence of prior therapies, headache diary, objective response measures). Missing required fields or missing attachments increases risk of delayed processing or denial.

Member name, DOB, member ID (UMI)
Ordering/attending provider name, NPI, address, office contact, phone, fax
Servicing facility/vendor name and NPI
ICD‑10 diagnosis code(s) and requested start date of service
Drug name and HCPCS/J‑code, dose/units, frequency, number of visits requested
Indication‑specific fields and attachments (e.g., headache diary for chronic migraine; documentation of severe focal hyperhidrosis and prior topical/systemic therapy trials for hyperhidrosis)
Attach documentation of prior therapy trials, reasons for failure/intolerance/contraindication, and any objective response measures (e.g., HDSS for hyperhidrosis)

Key Definitions

inv-13: Definition — Chronic migraine

DefinitionRecurrent debilitating headache established using the International Classification of Headache Disorders, Third Edition (ICHD-III).

Documentation requirementPersistent three-month history documented by the member via a headache diary or calendar.

Specialist involvementRequest must be prescribed by or in consultation with a neurologist or headache specialist.

AdministrationMust be administered by a healthcare provider trained in botulinum toxin administration.

Prior therapy trialsMember must have tried and failed adequate trials of prophylactic therapy from at least two different therapy classes (e.g., antiseizure, beta blocker, tricyclic antidepressant).

Continuation thresholdFor continuation requests, objective response required: ≥50% reduction in headache frequency or hours from baseline since starting botulinum toxin.

inv-14: Definition — Severe hyperhidrosis

DefinitionFocal excessive sweating (axillary, palmar, plantar, craniofacial, or other) described as severe hyperhidrosis.

Prior topical therapyTopical products such as 20% aluminum chloride or other extra‑strength antiperspirants must have been ineffective or caused a severe rash.

Systemic therapyMember must have been unresponsive to or unable to tolerate systemic pharmacotherapy for excessive sweating (e.g., anticholinergics, beta‑blockers, benzodiazepines).

Clinical consequencesDocumentation of recurrent skin maceration with bacterial or fungal infections or persistent atopic dermatitis despite treatments when applicable.

Treatment regionsRegion(s) treated should be specified (axillary, palmar, plantar, craniofacial, or other).

Continuation responseFor continuation, documented objective measurable improvement is required (e.g., improvement in Hyperhidrosis Disease Severity Scale (HDSS)).

Background

Chronic migraine is characterized by frequent, disabling headaches and is evaluated using the International Classification of Headache Disorders, Third Edition (ICHD-III). The prior authorization form requests objective documentation of a persistent three-month history of recurrent debilitating headache via a headache diary or calendar to establish frequency and duration. Botulinum toxin injections are administered in the outpatient setting by a healthcare provider trained in botulinum toxin administration; the form also captures whether the request is prescribed by or in consultation with a neurologist or headache specialist as part of medical necessity evaluation.