CurrentHighmark DelawarePolicy N/A

Outpatient Botulinum Toxin (Botox) Injectable Request Form - Coverage Criteria

A payer form and checklist to request prior authorization for outpatient botulinum toxin injections (medical benefit) for conditions including chronic migraine and hyperhidrosis; used by ordering providers, facilities, and vendors serving Highmark Delaware members.

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Botulinum Toxin (Botox) Injectable Request Form - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed prior authorization form with indication-specific documentation to 833-581-1861 to avoid delay or denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3primary indication sections

4listed botulinum toxin J-codes

833-581-1861submission fax number

Coverage Criteria for Outpatient Botulinum Toxin Injections

Chronic migraine (initial and continuation)

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Chronic migraine coverage prerequisites: 1) Diagnosis meets ICHD-III criteria for chronic migraine; 2) Persistent 3-month history of recurring debilitating headache documented (e.g., headache diary or calendar); 3) Member has documented headache frequency and duration (days/month and hours/day); 4) Trials and failures (or intolerance/contraindication) of prophylactic therapy from at least two different therapy classes with adequate doses/durations (e.g., ~6 weeks each) and listing of prior prophylactic therapies; 5) Request is identified as New Start or Continuation of Therapy on the form; 6) Request is prescribed by or in consultation with a neurologist/headache specialist (checkbox on form); 7) A healthcare provider trained in administration of botulinum toxin will administer the injection (checkbox on form); 8) For continuation requests: documented objective measurable improvement since starting botulinum toxin (examples: >=50% reduction in headache frequency or >=50% reduction in headache hours from baseline).>=50% improvement for continuation

Form captures each element via checkboxes/questions

Focal hyperhidrosis (initial and continuation)

Covered when ALL of the following are documented on the form:

Focal hyperhidrosis coverage prerequisites: 1) Member has severe focal hyperhidrosis (checkbox); 2) Focal treatment region(s) specified (axillary, palmar, plantar, craniofacial, or other); 3) History of failure or intolerance to topical antiperspirants (e.g., 20% aluminum chloride) and/or systemic/pharmacologic therapies (ex: anticholinergics) documented; 4) Documentation of history of recurrent skin maceration with bacterial or fungal infections or atopic dermatitis despite medical treatments when applicable; 5) Request is identified as New Start or Continuation of Therapy on the form; 6) For continuation requests: documentation of objective clinical response since starting treatment (checkboxes capture response for migraine section; hyperhidrosis continuation response captured via general continuation question and attached documentation).

Form asks checkbox questions to document each item

Other indications

Covered when ALL of the following are documented on the form:

Other indications: 1) List of therapies tried and failed, not tolerated, or contraindicated for the diagnosis is provided on the form; 2) Request is identified as New Start or Continuation of Therapy; 3) For continuation requests: documentation of a documented positive clinical response to treatment is provided (attachments may be included and are indicated on the form).

Supporting attachments may be included

The request form is structured to document specific prerequisites that support medical necessity for botulinum toxin injections. Requests that do not include the form‑requested evidence are effectively excluded because the form collects the required elements: for chronic migraine this includes confirmation that the diagnosis meets ICHD‑III criteria, a documented persistent three‑month history of recurring debilitating headache (e.g., diary/calendar), trials and failures (or intolerance/contraindication) of prophylactic therapy from at least two different classes at adequate doses/durations, and confirmation that a provider trained in botulinum toxin administration will deliver the treatment; for focal hyperhidrosis the form documents severity, the focal region(s), and failure or intolerance of topical and systemic therapies. Absent these completed fields — for example, missing prior therapy trial documentation, lack of specialty involvement when requested, or no documentation that the injector is trained — the submission lacks the form‑based support for coverage.

For continuation requests the form requires objective, measurable evidence of treatment benefit. Specifically for chronic migraine the form asks whether headache frequency or headache hours have been reduced by at least 50% from baseline since starting botulinum toxin; it also asks more generally whether there is a documented objective measurable effect indicating a positive clinical response. Continuation requests that do not document these objective improvements (for migraine: <50% reduction in frequency or hours, or no other documented positive clinical response) are not supported by the form criteria. For other indications the form likewise asks that a documented positive clinical response be attached or noted for continuation requests.

Codes and Medication Trial Details

Listed botulinum toxin J-codes on formHCPCS

J0585	BOTOX
J0586	DYSPORT
J0587	MYOBLOC
J0588	XEOMIN

Adequate medication trial duration example

Example adequate trial duration6 weeks each

Documentation fieldForm asks: 'Were the above medications prescribed at adequate doses for reasonable lengths of time (ex: 6 weeks each)?'

Use in prior therapy requirementApplied to prophylactic therapies for chronic migraine (at least two different classes)

Provider Submission and Documentation Requirements

Prior Authorization

Prior Authorization Required — Use Specific Request Form

Prior Authorization and related documentation must be submitted using the Outpatient Medical Injectables Botulinum Toxin Request Form. Fax the completed form to 833-581-1861 (Medical Benefit Only). Failure to submit the required form and supporting documentation may delay review or result in denial of the request.

Fax number: 833-581-1861 (Medical Benefit Only).
Use the specific Botulinum Toxin Request Form — submissions on other forms or without the form may be delayed or denied.

Documentation Required

Required Form Fields and Clinical Details

The request form must include complete patient and provider demographics, clinical indication, and documentation specific to the condition treated. Missing required fields or incomplete prior therapy documentation (for example, failure to document trials of at least two different prophylactic medication classes for chronic migraine) may result in denial or delay.

Required form fields: Member name, DOB, Member ID (UMI).
Ordering/Attending provider name, NPI, address, office contact phone and fax.
Servicing facility/vendor name, facility NPI and address.
ICD-10 diagnosis code(s) and Requested Start Date of Service.
Indicate payer type (Medicare or Commercial) and whether medication is Buy & Bill or supplied by Specialty Pharmacy (include pharmacy name and NPI if applicable).
For indication-specific sections, complete the applicable checklist (e.g., chronic migraine, hyperhidrosis, other uses).
Medication selection and administration details: product (e.g., BOTOX J0585, DYSPORT J0586, etc.), dose/units, frequency, and number of visits requested.

Denial Risk

Incomplete Prior Therapy Documentation — Risk of Denial or Delay

For chronic migraine requests, the form must document headache frequency/duration, duration of the condition, whether a neurologist or headache specialist is involved, confirmation of ICHD‑III diagnostic criteria, headache diary or calendar evidence of a persistent three‑month history, exclusion of medication rebound or lifestyle causes, and documentation of trials and failures (or contraindications/intolerance) of prophylactic therapies from at least two different classes. Incomplete prior therapy documentation will commonly delay or cause denial of coverage.

Document how many days per month headaches occur and typical hours per day.
State duration of migraine history and whether prescribed by/consulted with a neurologist or headache specialist.
Confirm ICHD‑III diagnostic criteria and attach headache diary/calendar documenting a persistent three‑month history.
List all prior prophylactic therapies tried, including drug name, class, dose, duration, and reason for discontinuation (failed, not tolerated, or contraindicated).
Indicate whether prior medications were given at adequate doses for reasonable durations (example: ~6 weeks).
Specify product requested and dosing (e.g., BOTOX J0585 — units, frequency).

Background and Purpose

The form collects clinical details intended to demonstrate medical necessity for outpatient botulinum toxin injections across common indications. For chronic migraine it captures headache days per month, hours per episode, duration of the headache history, whether the diagnosis meets ICHD‑III criteria, a persistent three‑month diary/calendar history, prior prophylactic therapies tried and their adequacy (for example, doses/durations such as e.g., 6 weeks each), whether a neurologist/headache specialist prescribed or consulted, and whether a provider trained in botulinum toxin administration will give the injections. For focal hyperhidrosis the form documents presence of severe focal hyperhidrosis, the treated region(s) (axillary, palmar, plantar, craniofacial, or other), prior failure or intolerance of topical agents (for example, 20% aluminum chloride) and systemic pharmacotherapy (anticholinergics), and features that support medical necessity such as recurrent skin maceration or persistent atopic dermatitis despite treatment. For all other uses the form requests a list of prior therapies tried and failed or not tolerated, the indication of new start versus continuation, and documentation of any positive clinical response for continuation requests.

Definitions

Chronic migraine — definition / ICHD-III reference

Definition referenceChronic migraine diagnosis must be established using the International Classification of Headache Disorders, Third Edition (ICHD-III)

Duration requirementPersistent three-month history of recurring debilitating headache documented (e.g., headache diary or calendar)

Required documentation on formHeadache frequency (days/month) and typical duration (hours/day) are requested on the form

Specialist involvementForm asks whether prescribed by or in consultation with a neurologist or headache specialist

Focal hyperhidrosis — definition and clinical qualifiers

Core definitionSevere, focal excessive sweating in discrete regions (axillae, palms, soles, craniofacial, or other)

Topical therapy failureForm documents whether topical products such as 20% aluminum chloride or other extra-strength antiperspirants have been ineffective or caused severe rash

Systemic therapy failure/intoleranceForm asks if member has been unresponsive or unable to tolerate pharmacotherapy for excessive sweating (e.g., anticholinergics)

Clinical qualifiersForm captures history of recurrent skin maceration with bacterial/fungal infections or atopic dermatitis despite treatments as supporting features