Neighborhood Health Plan RI Botox Coverage & Prior Auth

Coverage Criteria for OnabotulinumtoxinA (Botox)

inv-01: Universal Criteria

Covered when ALL of the following are met

Universal criteria: Patient is at least 18 years of age unless otherwise specified; and patient is not on concurrent treatment with another botulinum toxin.

See indication-specific nodes for age exceptions and additional requirements.

inv-02: Blepharospasm

Covered when ALL of the following are met

Blepharospasm: Patient is at least 12 years of age.

inv-03: Cervical Dystonia

Covered when ALL of the following are met

Cervical Dystonia: Patient is at least 16 years of age; and history of recurrent involuntary contraction of one or more muscles in the neck and upper shoulders; and either sustained head tilt OR abnormal posturing with limited range of motion in the neck.

inv-04: Strabismus

Covered when ALL of the following are met

Strabismus: Patient is at least 12 years of age.

inv-05: Spastic Conditions

Covered when ALL of the following are met

Spastic conditions list: Patient has one of the following: adult upper or lower limb spasticity; pediatric upper limb spasticity (age ≥2 years); pediatric lower limb spasticity (age ≥2 years); spasticity due to multiple sclerosis (or Schilder's disease); acquired spasticity secondary to spinal cord or brain injuries; spastic plegic conditions (monoplegia, diplegia, hemiplegia, paraplegia, quadriplegia); or hemifacial spasm.

Specific age thresholds and indication details vary by item.

inv-06: Severe Primary Axillary Hyperhidrosis

Covered when ALL of the following are met

Severe Primary Axillary Hyperhidrosis: Patient has tried and failed a ≥1 month trial of a topical agent (e.g., aluminum chloride, glycopyrronium, etc.); AND either history of medical complications such as skin infections or significant functional impairments OR significant burden of disease/impact to activities of daily living.

One of the last two conditions (complications OR functional impact) is required.

inv-07: Chronic Migraine Prophylaxis

Covered when ALL of the following are met

Prophylaxis for Chronic Migraines: Patient is using prophylactic intervention modalities; has ≥15 headache days per month for ≥3 months; has had ≥5 attacks with features consistent with migraine; on ≥8 days/month for ≥3 months headaches consistent with migraine OR headaches relieved by a triptan/ergot derivative; AND has failed at least an 8‑week trial of any two oral preventive medications.

See policy for examples of migraine‑prophylactic medications.

inv-08: Esophageal Achalasia

Covered when ANY of the following are met

Esophageal Achalasia: Patient is high risk for complication from pneumatic dilation, surgical myotomy, or POEM; OR has had treatment failure with those procedures; OR has had perforation from pneumatic dilation; OR has an epiphrenic diverticulum or hiatal hernia; OR has esophageal varices.

inv-09: Focal Dystonias

Covered when ANY of the following are met

Focal Dystonias: Includes focal upper limb dystonia (with functional impairment or pain), laryngeal dystonia, and oromandibular dystonia (with functional impairment or pain).

inv-10: Sialorrhea

Covered when ALL of the following are met

Sialorrhea associated with Neurological Disorders: History of troublesome sialorrhea for at least 3 months; AND patient has Parkinson's disease OR severe developmental delays OR cerebral palsy OR amyotrophic lateral sclerosis.

inv-11: Neurogenic Detrusor Overactivity

Covered when ALL of the following are met

Incontinence due to Detrusor Overactivity: Patient is at least 5 years of age; AND no current untreated urinary tract infection; AND detrusor overactivity associated with a neurologic condition confirmed by urodynamic testing; AND failed a ≥1 month trial of two medications from antimuscarinic or beta-adrenergic classes.

Medication examples listed in policy (e.g., darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium, mirabegron).

inv-12: Overactive Bladder

Covered when ALL of the following are met

Overactive Bladder (OAB): No current untreated urinary tract infection; AND symptoms of urge urinary incontinence, urgency, and frequency; AND failed a ≥1 month trial of two medications from antimuscarinic and/or beta-adrenergic classes.

Medication examples listed in policy (e.g., darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium, mirabegron).

inv-13: Severe Palmar Hyperhidrosis

Covered when ALL of the following are met

Severe Palmar Hyperhidrosis: Patient has tried and failed a ≥1 month trial of a topical agent; AND has failed iontophoresis; AND either history of medical complications such as skin infections or significant functional impairments OR significant impact to activities of daily living due to the condition.

One of the last two conditions (complications OR functional impact) is required.

inv-14: Overactive Bladder (Initial Coverage)

Covered when ALL of the following are met

OAB initial criteria: Patient does not have a current, untreated urinary tract infection; AND Patient has symptoms of urge urinary incontinence, urgency, and frequency; AND Patient has failed a 1 month or longer trial of two medications from either the antimuscarinic and/or beta-adrenergic classes.

Medication examples listed (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium, mirabegron).

inv-15: Severe Palmar Hyperhidrosis (Initial Coverage)

Covered when ALL of the following are met

Severe palmar hyperhidrosis criteria: Patient has tried and failed a ≥1 month trial of a topical agent; AND patient has failed iontophoresis; AND (patient has history of medical complications such as skin infections or significant functional impairments OR significant impact to activities of daily living due to condition).

One of the last two conditions is required (OR).

inv-16: Chronic Anal Fissure (Initial Coverage)

Covered when ALL of the following are met

Chronic anal fissure criteria: Other causes of disease have been ruled out (e.g., Crohn's Disease); AND patient has failed non-pharmacologic supportive measures (e.g., sitz baths, psyllium fiber); AND patient has tried and failed a ≥1 month trial of conventional pharmacologic therapy (e.g., nifedipine, diltiazem, topical nitroglycerin).

Conservative and pharmacologic therapy failure required.

inv-17: Ventral Hernia (Preoperative Use)

Covered when ALL of the following are met

Ventral hernia preoperative use: Patient has a large ventral hernia with loss of domain or a contaminated ventral hernia; AND used preoperatively in patients scheduled to receive abdominal wall reconstruction (AWR).

This preoperative requirement does not apply to MMP members; Ventral Hernia one-time 500‑unit dosing may not be renewed.

inv-18: Renewal Criteria (Overall and Indication-Specific Responses)

Coverage can be renewed based upon the following criteria

Universal renewal criteria: Patient continues to meet universal and indication-specific criteria; AND absence of unacceptable toxicity from the drug; AND evidence of disease response by indication-specific measures.

See child nodes for per-indication response measures.

Blepharospasms response: Improvement of severity and/or frequency of eyelid spasms.

Cervical dystonia response: Improvement in severity and frequency of pain; AND improvement of abnormal head positioning.

Strabismus response: Improvement in alignment measured in prism diopters compared to pre-treatment baseline.

inv-19: Incontinence due to Detrusor Overactivity

Continuation/response criteria for Detrusor Overactivity (neurogenic bladder): Covered when ALL of the following are met

Detrusor Overactivity continuation: Patient does not have a current, untreated urinary tract infection.

Detrusor Overactivity continuation: Significant improvements in weekly frequency of incontinence episodes.

Detrusor Overactivity continuation: Patient's post-void residual (PVR) periodically assessed as medically appropriate.

inv-20: Overactive Bladder (OAB)

Continuation/response criteria for Overactive Bladder (OAB): Covered when ALL of the following are met

OAB continuation: Patient does not have a current, untreated urinary tract infection.

OAB continuation: Significant improvement in daily frequency of urinary incontinence or micturition episodes and/or volume voided per micturition.

OAB continuation: Patient's post-void residual (PVR) periodically assessed as medically appropriate.

inv-21: Severe Palmar Hyperhidrosis

Criteria for Severe Palmar Hyperhidrosis response

Palmar Hyperhidrosis response: Significant reduction in spontaneous palmar sweat production.

Palmar Hyperhidrosis response: Patient has a significant improvement in activities of daily living.

inv-22: Chronic Anal Fissure

Criteria for Chronic Anal Fissure response

Anal fissure response: Complete healing of the anal fissure OR symptomatic improvement of persistent fissures.

inv-23: Spastic Conditions, Other

Criteria for Spastic Conditions (other)

Spasticity response: Decrease in tone and/or resistance of affected areas based on a validated measuring tool (e.g., Ashworth Scale, Physician Global Assessment, Clinical Global Impression).

inv-24: Dosing and Interval Constraints

Dosing criteria and limits (per-indication dosing and global dosing constraints)

Neurogenic bladder (adults): 200 Units per treatment injected into the detrusor using 30 injections (6.7 units each); re-inject no sooner than 12 weeks.200 U

Overactive Bladder (OAB): 100 Units per treatment injected into the detrusor using 20 injections (5 units each); re-inject no sooner than 12 weeks.100 U

Chronic Migraine: 155 Units administered IM across 7 head/neck muscle areas; re-treatment every 12 weeks.155 U

inv-25: Ventral Hernia (special case)

Special-case dosing limits

Ventral Hernia dose = 500 Units divided among abdominal muscles, injected 2–4 weeks prior to abdominal wall reconstruction (AWR) surgery; may not be renewed.500 U

inv-26: Covered Diagnoses (Appendix 1)

Covered diagnoses (Appendix 1) — selection provided in this segment

Appendix 1 covered diagnoses: Treatment with onabotulinumtoxinA is listed as covered when billed with one of the ICD-10 diagnosis codes enumerated in Appendix 1 (selected codes provided in the appendix).

See Appendix 1 for the full list of ICD-10 codes.

inv-27: Covered diagnoses (appendix)

Covered when the billed diagnosis is one of the listed ICD-10 codes in the appendix

Appendix diagnosis requirement: The diagnosis code submitted for the Botox service must be one of the ICD-10 codes listed in Appendix 1.

See code groups for exact codes.

inv-28: Dual coding payable criteria

Payment condition

Dual coding payable condition: Primary G and M ICD-10 diagnosis codes are payable only if accompanied by a secondary G or I code.

Failure to include the required secondary code may result in non-payment.

The policy specifies that preoperative administration of onabotulinumtoxinA for Ventral Hernia is a one-time intervention and may NOT be renewed. Coverage length language indicates initial authorization rules and explicitly states the preoperative Ventral Hernia use cannot be repeated as a renewal.

The Ventral Hernia preoperative-use requirement includes a specific exception: the requirement to use onabotulinumtoxinA preoperatively does not apply to MMP members. Providers submitting requests for MMP members should note this exception when documenting indication and need.

For the Ventral Hernia indication the policy defines a single preoperative dosing regimen of 500 units (divided among abdominal muscles and injected 2–4 weeks prior to abdominal wall reconstruction). The policy explicitly states this administration may not be renewed, meaning no ongoing or repeat coverage is provided beyond that one preoperative 500‑unit administration.

This document segment does not enumerate specific exclusions beyond indication‑level notes. Clinicians and billing staff should consult the full policy and the cited Local Coverage Articles (LCDs) and contractor guidance in the References for any exclusionary rules or contractor‑specific limitations that may affect coverage or claims adjudication.

The policy includes a dual coding requirement: claims using primary G and M diagnosis codes must be accompanied by a secondary G or I code to be payable. Submissions that include only the primary G or M code without the required companion code may be non-payable due to this coding condition.

Continuation of treatment is not considered medically necessary if the member experiences unacceptable toxicity or fails to demonstrate disease response as defined in the renewal criteria. The policy lists examples of unacceptable toxicities and requires objective evidence of improvement per the indication‑specific renewal measures.

The policy language for Ventral Hernia — stating that the preoperative 500‑unit administration may not be renewed — indicates there is no coverage for ongoing treatment beyond that single preoperative dose. Providers should not expect authorization for repeat or maintenance dosing for this indication.

This segment references multiple billing and coding Local Coverage Articles (LCDs) in the References but does not itself list explicit additional 'not medically necessary' exclusions. For complete exclusionary guidance and billing guidance, follow the full policy text and the cited LCDs and contractor policies.

Billing Codes, Diagnosis Codes, and Limits

Quantity Limits (Medical Benefit)mixed

Blepharospasm	Billable Units = 200; Per # days = 84
Cervical Dystonia	Billable Units = 300; Per # days = 84
Strabismus	Billable Units = 100; Per # days = 84
Esophageal Achalasia	Billable Units = 100; Per # days = 168
Adult Upper Limb Spasticity	Billable Units = 400; Per # days = 84
Adult Lower Limb Spasticity	Billable Units = 400; Per # days = 84
Chronic Migraine	Billable Units = 200; Per # days = 84
Severe Primary Axillary Hyperhidrosis	Billable Units = 100; Per # days = 112
Sialorrhea	Billable Units = 100; Per # days = 84
Neurogenic Bladder/Detrusor Overactivity	Billable Units = 200; Per # days = 84

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Quantity Limits (Medicaid Pharmacy Benefit)mixed

Botox

1 fill per 84 days

Covered HCPCS CodesHCPCSCovered

J0585

Injection, onabotulinumtoxinA, 1 unit; 1 billable unit = 1 unit

NDC CodesNDC

00023-1145	Botox 100 unit powder for injection; single-dose vial
00023-3921	Botox 200 unit powder for injection; single-dose vial

Covered ICD-10 Codes (selection start)ICD-10Covered

G11.4	Hereditary spastic paraplegia
G24.3	Spasmodic torticollis
G24.4	Idiopathic orofacial dystonia
G24.5	Blepharospasm
G24.9	Dystonia, unspecified
G25.89	Other specified extrapyramidal and movement disorders
G35	Multiple sclerosis
G37.0	Diffuse sclerosis of central nervous system
G43.701	Chronic migraine without aura, not intractable, with status migrainosus
G43.709	Chronic migraine without aura, not intractable, without status migrainosus

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Covered ICD-10 Codes (continued)ICD-10Covered

G80.0	Spastic quadriplegic cerebral palsy
G80.1	Spastic diplegic cerebral palsy
G80.2	Spastic hemiplegic cerebral palsy
G80.3	Athetoid cerebral palsy
G80.4	Ataxic cerebral palsy
G80.8	Other cerebral palsy
G80.9	Cerebral palsy, unspecified
G81.10	Spastic hemiplegia affecting unspecified side
G81.11	Spastic hemiplegia affecting right dominant side
G81.12	Spastic hemiplegia affecting left dominant side

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Covered ICD-10 cerebrovascular/neurologic codesICD-10Covered

I69.831	Monoplegia of upper limb following other cerebrovascular disease affecting right dominant side
I69.832	Monoplegia of upper limb following other cerebrovascular disease affecting left dominant side
I69.833	Monoplegia of upper limb following other cerebrovascular disease affecting right non-dominant side
I69.834	Monoplegia of upper limb following other cerebrovascular disease affecting left non-dominant side
I69.839	Monoplegia of upper limb following other cerebrovascular disease affecting unspecified site
I69.841	Monoplegia of lower limb following other cerebrovascular disease affecting right dominant side
I69.842	Monoplegia of lower limb following other cerebrovascular disease affecting left dominant side
I69.843	Monoplegia of lower limb following other cerebrovascular disease affecting right non-dominant side
I69.844	Monoplegia of lower limb following other cerebrovascular disease affecting left non-dominant side
I69.849	Monoplegia of lower limb following other cerebrovascular disease affecting unspecified site

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Covered ICD-10 non-neurologic and other codesICD-10Covered

J38.3	Other diseases of vocal cords
K43.6	Other and unspecified ventral hernia with obstruction, without gangrene
K43.7	Other and unspecified ventral hernia with gangrene
K43.9	Ventral hernia without obstruction or gangrene
K11.7	Disturbances of salivary secretions
K22.0	Achalasia of cardia
K60.1	Chronic anal fissure
L74.510	Primary focal hyperhidrosis, axilla
L74.512	Primary focal hyperhidrosis, palms
M43.6	Torticollis

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Dual coding requirementmixed

Requirement

Primary G and M codes require a secondary G or I code in order to be payable

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for onabotulinumtoxinA and other botulinum toxin indications. Coverage is initially authorized for six months (some uses renewable to 12 months) and quantity/dosing limits apply by indication. Preoperative use for Ventral Hernia is not renewable.

Prior authorization required for J0585 (onabotulinumtoxinA).
Initial authorization: 6 months; many indications renewable up to 12 months.
Quantity limits and maximum cumulative dosing are indication-specific (see quantity limit and dosing section).

Documentation Required

Prior Authorization — Documentation Expectations

Prior authorization requests must include documentation that the indication‑specific trial/failure criteria were met and that universal criteria are satisfied. Requests for bladder and urinary indications must document absence of a current, untreated UTI and any required medication trials. Renewal requests must show continued benefit and absence of unacceptable toxicity.

Background and Clinical Context

OnabotulinumtoxinA (Botox) is an approved therapeutic agent used across a range of neuromuscular and autonomic conditions, including dystonias, spasticity, hyperhidrosis, chronic migraine prophylaxis, and bladder indications such as neurogenic detrusor overactivity and overactive bladder. Clinical use requires adherence to indication‑specific age thresholds, dosing limits, and documentation requirements described elsewhere in the policy.

Definitions and Measurement Tools

Adult vs Pediatric age thresholds

General adult thresholdPatient is at least 18 years of age unless an indication-specific minimum is specified

Blepharospasm age minimumAge ≥12 years for blepharospasm

Pediatric spasticity age minimumPediatric upper/lower limb spasticity: age ≥2 years (specific dosing/limits apply)

Unacceptable toxicity / toxin spread effect

Examples of unacceptable toxicity / toxin spreadAsthenia, generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence, swallowing/breathing difficulties

Other severe adverse events listedSevere hypersensitivity reactions, reduced pulmonary function, corneal exposure/ulceration, autonomic dysreflexia

OpenPayer

Botox® (onabotulinumtoxinA) — Coverage Criteria

Coverage Criteria for OnabotulinumtoxinA (Botox)

Billing Codes, Diagnosis Codes, and Limits

Prior Authorization, Documentation, and Billing Guidance

Background and Clinical Context

Definitions and Measurement Tools