CurrentHighmark DelawarePolicy N/A

Outpatient Medical Injectables Botulinum Toxin Request Form

A payer request/authorization form for outpatient administration of botulinum toxin (medical benefit) documenting member, provider, diagnosis, therapy history, and indication-specific questions for chronic migraine, hyperhidrosis, and other uses. Used to support prior authorization and billing decision for botulinum toxin products.

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Medical Injectables Botulinum Toxin Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must complete and fax the Outpatient Medical Injectables Botulinum Toxin Request Form to 833-619-5745 including member, provider, ICD-10 diagnosis code(s), date of service, indication-specific history, prior therapies, and requested J-code.

POLICY UPDATE CHANGES

No material clinical/coverage changes reported.

4Botulinum product J-codes listed

3Indication sections

Policy Summary

This is the Highmark Delaware Outpatient Medical Injectables Botulinum Toxin Request Form (Medical Benefit Only) used to collect clinical information to support prior authorization and billing decisions for botulinum toxin administered in outpatient settings. The form captures member and provider identifiers (member name, DOB, UMI, requesting physician, NPI, facility and contact information), ICD-10 diagnosis code(s), date of service, and whether the drug is supplied by a specialty pharmacy or billed as buy & bill.

The form collects indication-specific history and required clinical details (for chronic migraine: headache days/month, hours/day, duration, specialty consultation, administration training, ICHD-III diagnosis confirmation, three-month headache diary/calendar, exclusion for medication rebound or lifestyle causes, prior prophylactic therapy trials and adequacy of doses/duration, and requested J-code like J0585, J0586, J0587, J0588); for hyperhidrosis: severity, focal region, history of skin infections or atopic dermatitis, prior/topical/systemic therapies tried or not tolerated, request type (new or continuation), and objective response measures (eg, HDSS); and for other uses: therapies tried/failed, request type, and documented response.

Subject: Outpatient Medical Injectables Botulinum Toxin Request Form. Current status: CURRENT. Providers must complete and fax the form to 833-619-5745 including member, provider, ICD-10 code(s), date of service, indication-specific history, prior therapies, and requested HCPCS J-code to support prior authorization and billing.

Key Facts

PayerHighmark Delaware

SubjectOutpatient Medical Injectables Botulinum Toxin Request Form

Doc typereimbursement_rule

StatusCURRENT

Indications listedChronic Migraine; Hyperhidrosis; Other

Botulinum J-codes listedJ0585, J0586, J0587, J0588 (4 codes)

Authorization Criteria

Chronic Migraine - Authorization Information

Questions to document clinical criteria for chronic migraine and prior therapy

ALL of the following

Member experiences headache days per month (document number)
Duration of migraine hours per day (document number)
Duration of chronic migraine history (document length of time)
Is this request prescribed by or in consultation with a neurologist or headache specialist?
Yes/No checkbox
Is a healthcare provider trained in administration of botox administering the drug?
Yes/No checkbox
Has the diagnosis of chronic migraine been established using ICHD-III?
Yes/No checkbox
Has there been a persistent three-month history of recurring debilitating headache documented via headache diary or calendar?
Yes/No checkbox
Are headaches caused by medication rebound or lifestyle issues?
Yes/No checkbox
Has the member tried and failed adequate trials of prophylactic therapy from at least two different therapy classes (ex: antiseizure, beta blocker, tricyclic antidepressant)?
Yes/No checkbox; list prior prophylactic therapies, verify adequate doses/duration (example: 6 weeks each)
Requested Botulinum Product
- BOTOX (J0585)
- DYSPORT (J0586)
- MYOBLOC (J0587)
- XEOMIN (J0588)
- Other (J_____)

ref

title": "Chronic Migraine - Authorization Information"}

ref": "b1_0"

title":

Hyperhidrosis - Authorization Information

For continuation requests document objective clinical response since starting therapy

ALL of the following

Since starting Botox has the member's migraine headache frequency reduced by at least 50% from baseline?>= 50% reduction from baseline
Yes/No checkbox
Since starting Botox has the member's migraine headache hours reduced by at least 50% from baseline?>= 50% reduction from baseline
Yes/No checkbox

ref": "b1_1"

title":

Other Uses - Authorization Information

Questions to document severity, region treated, prior topical/systemic therapy, and contraindications

ALL of the following

Does the member have severe hyperhidrosis?
Yes/No checkbox
Focal region to be treated (Axillary, Palmar, Plantar, Craniofacial, Other)
Circle all that apply
History of recurrent skin maceration with bacterial or fungal infections?
Yes/No checkbox
History of atopic dermatitis despite medical treatments with topical dermatologic or systemic anticholinergic agents?
Yes/No checkbox

Code Lists

Billable J-codes for Botulinum Neurotoxin ProductsHCPCS

J0585	BOTOX
J0586	DYSPORT
J0587	MYOBLOC
J0588	XEOMIN

Other Procedure / Diagnosis Codes (to be provided on form)ICD-10

No codes listed

What Providers Must Do

Prior Authorization

Submit completed botulinum toxin request form

Providers must complete and fax the Outpatient Medical Injectables Botulinum Toxin Request Form (Medical Benefit Only) to 833-619-5745. The form must include member and provider information, ICD-10 diagnosis code(s), date of service, indication-specific history, prior therapies, and the requested J-code.

J0585
J0586
J0587
J0588

Documentation Required

Document prior therapy trials and response

For chronic migraine and hyperhidrosis, document prior treatments tried and failed (including therapy classes and durations), objective measures of response (e.g., headache diary or calendar for migraine; HDSS for hyperhidrosis), and include specialty consultation when required (for example, neurologist or headache specialist).

Billing Rule

Verify eligibility and benefit

Verify the member's eligibility and benefits through the health plan prior to submission and billing.

Continuation / Prior Therapy Thresholds

Migraine frequency reduction for continuation>= 50% reduction from baseline

Migraine hours reduction for continuation>= 50% reduction from baseline

Prior prophylactic therapy classesTrials from at least two different therapy classes

Key Terms

Definitions

ICHD-IIIInternational Classification of Headache Disorders, Third Edition

HDSSHyperhidrosis Disease Severity Scale (example objective measure for response)

Form Purpose & Use

This authorization/billing form is used by Highmark Delaware to collect clinical information for outpatient administration of botulinum toxin under the medical benefit, capturing indication-specific criteria for chronic migraine, hyperhidrosis, and other uses to inform coverage decisions.

For chronic migraine the form documents headache frequency, duration, specialty consultation (neurologist/headache specialist), administration training, ICHD-III diagnosis confirmation, a persistent three-month headache diary/calendar, exclusion of medication rebound/lifestyle causes, and prior prophylactic therapy trials from at least two different therapy classes with adequacy of doses/duration. Requested botulinum products are captured by HCPCS J-codes such as J0585, J0586, J0587, and J0588.

For hyperhidrosis the form documents severity, focal treatment region, history of recurrent skin maceration or atopic dermatitis despite treatments, prior topical/systemic therapies tried or not tolerated (eg, 20% aluminum chloride, anticholinergics), request type (new or continuation), and objective response since starting botulinum toxin (for example improvement in HDSS).

For other indications the form collects therapies tried and failed or not tolerated, request type (new or continuation), and whether a documented positive clinical response to treatment exists. The form also instructs providers to verify member eligibility and benefits prior to submission.

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Medical Injectables Botulinum Toxin Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

On This Page

title": "Chronic Migraine - Continuation Criteria / Response Assessment"

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Has the member been unresponsive or unable to tolerate pharmacotherapy modalities prescribed for excessive sweating (ex: anticholinergics, beta-blockers, benzodiazepines)?

Have topical products such as 20% aluminum chloride or other extra strength antiperspirants been ineffective or resulted in a severe rash?

Yes/No checkbox

Request Type

New Start
Continuation of Therapy

Requested Botulinum Product (implicit)

BOTOX (J0585)
DYSPORT (J0586)
MYOBLOC (J0587)
XEOMIN (J0588)
Other (J_____)

title": "Other Uses - Authorization Information"

OpenPayer

Outpatient Medical Injectables Botulinum Toxin Request Form

Policy Summary

Authorization Criteria

Code Lists

What Providers Must Do

Key Terms

Form Purpose & Use

Document History