Neighborhood Health Plan Botox Coverage Update

Coverage and Medical Necessity Criteria

Universal/Initial Approval 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; and indication-specific criteria are met.

Blepharospasm

Covered when ALL of the following are met:

Blepharospasm: Patient is at least 12 years of age.

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.

Strabismus

Covered when ALL of the following are met:

Strabismus: Patient is at least 12 years of age.

Spastic Conditions

Covered when ANY of the following spastic conditions are present:

Spastic conditions list: Includes adult upper or lower limb spasticity; pediatric upper or lower limb spasticity in patients aged ≥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, including hereditary spastic paraplegia); and hemifacial spasm.

Severe Primary Axillary Hyperhidrosis

Covered when ALL of the following are met:

Axillary hyperhidrosis: Patient has tried and failed a ≥1 month trial of a topical agent (e.g., aluminum chloride or glycopyrronium); and either has a history of medical complications (e.g., skin infections) OR has significant burden/impact to activities of daily living (work, social function, frequent clothing changes, etc.).

Prophylaxis for Chronic Migraines

Covered when ALL of the following are met:

Chronic migraine prophylaxis: Patient is using prophylactic interventions (pharmacotherapy, behavioral therapy, physical therapy, etc.); and has ≥15 headache days per month for at least 3 months; and has had at least five attacks with features consistent with migraine; and on ≥8 days/month for ≥3 months headaches have migraine characteristics or are relieved by a triptan/ergot; and patient failed at least an 8-week trial of two oral preventive medications.

Esophageal Achalasia

Covered when ANY of the following are met:

Achalasia criteria: Patient is high risk for complication from pneumatic dilation, surgical myotomy, or POEM; OR has failed pneumatic dilation, surgical myotomy, or POEM; OR has had perforation from pneumatic dilation; OR has an epiphrenic diverticulum or hiatal hernia; OR has esophageal varices.

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).

Sialorrhea associated with Neurological Disorders

Covered when ALL of the following are met:

Sialorrhea: 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 (ALS).

Incontinence due to Detrusor Overactivity

Covered when ALL of the following are met:

Detrusor overactivity: Patient is at least 5 years of age; and patient does not have a current, untreated urinary tract infection; and detrusor overactivity associated with a neurologic condition is confirmed by urodynamic testing; and patient has failed a ≥1 month trial of two medications from either the antimuscarinic or beta-adrenergic classes.

Overactive Bladder (OAB)

Covered when ALL of the following are met:

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

Incontinence due to Detrusor Overactivity (alternate slot)

Covered when ALL of the following are met for Incontinence due to Detrusor Overactivity:

Neurogenic detrusor overactivity coverage criteria: Patient is at least 5 years of age

UTI exclusion: Patient does not have a current, untreated urinary tract infection

Diagnostic confirmation: Detrusor overactivity associated with a neurologic condition is confirmed by urodynamic testing

Medication trial: Patient has failed a 1 month or longer trial of two medications from either the antimuscarinic (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium) or beta-adrenergic (mirabegron) classes1 month; two medications

Overactive Bladder (OAB) (alternate slot)

Covered when ALL of the following are met for Overactive Bladder (OAB):

UTI exclusion: Patient does not have a current, untreated urinary tract infection

Symptom requirement: Patient has symptoms of urge urinary incontinence, urgency, and frequency

Medication trial: Patient has failed a 1 month or longer trial of two medications from either the antimuscarinic (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium) and/or beta-adrenergic (mirabegron) classes1 month; two medications

Severe Palmar Hyperhidrosis

Covered when ALL of the following are met for Severe Palmar Hyperhidrosis:

Topical therapy failure: Patient has tried and failed a ≥1 month trial of a topical agent (e.g., aluminum chloride)≥ 1 month

Iontophoresis failure: Patient has failed iontophoresis

Impact requirement (one of): Patient has medical complications (e.g., skin infections) OR significant impact to activities of daily living

Chronic Anal Fissure

Covered when ALL of the following are met for Chronic Anal Fissure:

Exclude other causes: Other causes of disease have been ruled out (e.g., Crohn's Disease)

Supportive measures failure: Patient has failed non-pharmacologic supportive measures (e.g., sitz baths, psyllium fiber, bulking agents)

Pharmacologic trial failure: Patient has tried and failed a ≥1 month trial of conventional pharmacologic therapy (e.g., nifedipine, diltiazem, topical nitroglycerin)≥ 1 month

Ventral Hernia (preoperative)

Covered when ALL of the following are met for Ventral Hernia (preoperative use):

Hernia severity: Patient has a large ventral hernia with loss of domain or a contaminated ventral hernia

Planned use: Used preoperatively in patients scheduled to receive abdominal wall reconstruction (AWR) (this requirement does not apply to Medicare members)

Preoperative use may not be renewed

Migraine Prophylaxis (diagnostic and prior therapy considerations)

Covered for Migraine prophylaxis when diagnosis criteria met and prior therapies considered:

Migraine without aura diagnostic criteria: At least five attacks lasting 4-72 hours with at least two characteristic features (unilateral, pulsating, moderate/severe intensity, aggravated by routine activity) and at least one associated symptom (nausea/vomiting or photophobia and phonophobia)

Migraine with aura diagnostic criteria: At least two attacks with reversible aura symptoms and at least three aura characteristics (gradual spread ≥5 minutes, successive symptoms, individual aura duration 5-60 minutes, unilateral, positive symptom, headache within 60 minutes)

Consideration of oral prophylactic classes: Providers should consider prior use of migraine-prophylaxis oral medications across classes (antidepressants, beta blockers, ACE inhibitors/ARBs, antiepileptics, calcium channel blockers)

Sialorrhea associated with Neurological Disorders - Continuation/Renewal

Covered when ALL of the following are met:

Sialorrhea continuation criteria: Significant decrease in saliva production compared to baseline; clinical improvement must be documented for renewal.

Incontinence due to Detrusor Overactivity - Continuation/Renewal

Covered when ALL of the following are met:

Detrusor overactivity continuation criteria: Patient does not have a current, untreated urinary tract infection; and significant improvements in weekly frequency of incontinence episodes; and patient's post-void residual (PVR) is periodically assessed as medically appropriate.

Document UTI status, improvement in episode frequency, and PVR monitoring

Overactive Bladder (OAB) - Continuation/Renewal

Covered when ALL of the following are met:

OAB continuation criteria: Patient does not have a current, untreated urinary tract infection; and significant improvement in daily frequency of urinary incontinence or micturition episodes and/or volume voided per micturition; and patient's post-void residual (PVR) is periodically assessed as medically appropriate.

Document UTI status, symptom frequency/volume improvement, and PVR monitoring

Severe Palmar Hyperhidrosis - Continuation/Renewal

Covered when ALL of the following are met:

Palmar hyperhidrosis continuation criteria: Significant reduction in spontaneous palmar sweat production; and patient has a significant improvement in activities of daily living.

Document sweat reduction and ADL improvement

Chronic Anal Fissure - Continuation/Renewal

Covered when ANY of the following is met:

Chronic anal fissure continuation criteria: Complete healing of the anal fissure; OR symptomatic improvement of persistent fissures.

Document healing or symptom improvement

Spastic Conditions - Continuation/Renewal

Covered when ALL of the following are met:

Spasticity continuation criteria: 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); clinical improvement must be documented for renewal.

Use validated scale to document improvement

Ventral Hernia

Ventral hernia policy: Preoperative administration (single course) may be covered when criteria met; ventral hernia indication may not be renewed.

May not be renewed; coverage for preoperative use only

General medical necessity criteria

Covered when use aligns with plan P&T criteria and FDA labeling or accepted clinical literature

General coverage: Use must be for an FDA-approved or medically accepted indication as reviewed by the plan's P&T Committee; prescriber must provide supporting documentation and the plan will give individual consideration to each request; for Medicare members, applicable NCD/LCD take precedence.

Preoperative administration of onabotulinumtoxinA for the ventral hernia indication is covered as a single, preoperative use when criteria for large ventral hernia with loss of domain or contaminated hernia and planned abdominal wall reconstruction are met. Renewal is not permitted for this preoperative ventral hernia use; requests to extend or renew authorization for the ventral hernia indication will not be approved.

For urinary indications (both neurogenic detrusor overactivity and non-neurogenic overactive bladder), an active, untreated urinary tract infection (UTI) is an exclusion. Coverage requires documentation that no current untreated UTI exists prior to administration; if a UTI is present, it must be treated and resolved before the request will meet coverage criteria.

The policy allows a single preoperative administration of onabotulinumtoxinA for ventral hernia patients scheduled for abdominal wall reconstruction, but explicitly states that the ventral hernia indication may not be renewed. Renewal or continuation authorizations for this indication are disallowed.

For Medicare members, any applicable CMS determinations take precedence: an applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD) supersedes the plan's coverage criteria. The plan's criteria apply only when no relevant NCD/LCD exists; individual consideration will be given based on prescriber-submitted information.

Billing Codes, Units, and Coding Rules

Quantity and HCPCS unit limitsmixed

See table

Indication-specific max units and per-days limits (blepharospasm 200/84d; cervical dystonia 300/84d; strabismus 100/84d; esophageal achalasia 100/168d; adult upper/lower limb spasticity 400/84d; chronic migraine 200/84d; severe primary axillary hyperhidrosis 100/112d; sialorrhea 100/84d; neurogenic bladder 200/84d; overactive bladder 100/84d; chronic anal fissures 100/84d; palmar hyperhidrosis 200/168d; pediatric upper limb spasticity 200/84d; pediatric lower limb spasticity 300/84d; laryngeal dystonia 100/84d; hemifacial spasms 100/84d; oromandibular dystonia 200/84d; ventral hernia 500, per N/A; all other indications 400/90d)

Covered HCPCSHCPCSCovered

J0585

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

NDCNDCCovered

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

Covered ICD-10 Codes (partial list 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

Covered ICD-10 Codes (migraine, hemifacial spasm, cerebral palsy, paralysis etc.)ICD-10Covered

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
G43.711	Chronic migraine without aura, intractable, with status migrainosus
G43.719	Chronic migraine without aura, intractable, without status migrainosus
G43.E01	Chronic migraine with aura, not intractable, with status migrainosus
G43.E09	Chronic migraine with aura, not intractable, without status migrainosus
G43.E11	Chronic migraine with aura, intractable, with status migrainosus
G43.E19	Chronic migraine with aura, intractable, without status migrainosus

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Covered ICD-10 Codes (continued ophthalmologic and paralysis codes)ICD-10Covered

G81.10	Spastic hemiplegia affecting unspecified side
G81.11	Spastic hemiplegia affecting right dominant side
G81.12	Spastic hemiplegia affecting left dominant side
G81.13	Spastic hemiplegia affecting right nondominant side
G81.14	Spastic hemiplegia affecting left nondominant side
G82.20	Paraplegia, unspecified
G82.21	Paraplegia, complete
G82.22	Paraplegia, incomplete
G82.50	Quadriplegia, unspecified
G82.51	Quadriplegia, C1-C4 complete

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Covered ICD-10 Diagnosis Codes — Appendix 1 full code setICD-10Covered

I69.231	Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.232	Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.233	Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.234	Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.239	Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting unspecified site
I69.241	Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.242	Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.243	Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.244	Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.249	Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting unspecified site

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Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization, Documentation, and Provider Requirements

Prior authorization is required and must include documentation that indication-specific prerequisites are met. Submit clinical records demonstrating the condition-specific requirements (for example: failed medication trials with agent names and durations, diagnostic confirmation such as urodynamic testing for detrusor overactivity, age where pediatric criteria apply, absence of untreated UTI, PVR assessments when indicated, and objective measures of improvement for renewal). For Medicare members, plan coverage criteria apply only when no applicable NCD or LCD exists; when an NCD/LCD is present, the Medicare determination takes precedence. Requests will be reviewed individually and must include prescriber justification that use is for an FDA‑approved or medically accepted indication. Ventral hernia requests are eligible only as a single preoperative use and may not be renewed.

Include indication-specific documentation: failed medication trials (agents and durations), diagnostic confirmation (e.g., urodynamics for detrusor overactivity), age for pediatric neurogenic cases, and absence of current untreated UTI where required.
For detrusor overactivity: urodynamic testing confirming detrusor overactivity, documentation of two ≥1 month medication trials (antimuscarinic and/or mirabegron), and periodic post-void residual (PVR) assessment.
Appendix 1 diagnosis codes must be used on PA requests and claims; diagnoses not listed may not meet coverage criteria.
For Medicare members: follow NCD/LCD if present; otherwise the plan’s P&T Committee criteria apply.

Background and Definitions

Botox (onabotulinumtoxinA) is an acetylcholine release inhibitor and neuromuscular blocker administered by intramuscular, intradetrusor, or intradermal injection for multiple neurologic, urologic, and dermatologic conditions. Clinical benefit has been demonstrated across indications using disease-specific outcome measures (for example, reduced headache days for chronic migraine, validated spasticity scales for limb spasticity, and reduced sweat production for hyperhidrosis). Common adverse reactions reported include urinary tract infection, dysuria/urinary retention, neck pain, headache, dysphagia, and injection site pain. Coverage decisions are intended to align use with FDA labeling and accepted clinical literature.

Botox (onabotulinumtoxinA) — definition and administration routes

Pharmacologic classAn acetylcholine release inhibitor and neuromuscular blocker (onabotulinumtoxinA)

Administration routesAdministered via intramuscular, intradetrusor, or intradermal injection

Indications overviewUsed for multiple FDA‑approved indications including overactive bladder, chronic migraine prophylaxis, spasticity, cervical dystonia, and hyperhidrosis

Initial Therapy Requirements

Initial therapy requirements

Initial approval general rules

Initial therapy: Medicare members with prior receipt within the past 365 days are exempt from step therapy; patient must meet age and indication-specific criteria and any required prior medication trial requirements (e.g., migraine prevention failures, OAB/detrusor overactivity trials).

Initial therapy prerequisites

Initial coverage requires failure of specified conservative or pharmacologic measures and diagnostic confirmation where applicable

OAB/neurogenic bladder initial therapy: Failed a 1 month or longer trial of two medications from the antimuscarinic or beta-adrenergic classes; no active untreated UTI; urodynamic confirmation required for neurogenic detrusor overactivity.1 month; two medications

Renewal and Continuation Requirements

Continuation authorization

Renewal/continuation rules

Renewal: Coverage may be renewed for 12 months except preoperative ventral hernia which is not renewable.

Renewal / Continuation Therapy Criteria

Renewal (continuation) requires ongoing benefit and safety monitoring; indication-specific clinical response metrics are required

General renewal requirements: Patient continues to meet universal and indication-specific criteria and absence of unacceptable toxicity; and disease response demonstrated by indication-specific improvements.

Blepharospasm renewal metric: Improvement of severity and/or frequency of eyelid spasms.

Step Therapy and Prior Treatment Requirements

Requirement	Documentation to provide
Document prior medication trials relevant to the requested indication (e.g., migraine preventive agents, antimuscarinic or beta-adrenergic agents for OAB/detrusor overactivity)
Provide agent names, start and stop dates, trial durations, and clinical response (reason for failure or intolerance)

Indication-specific prior therapy requirement	Minimum trial / expected documentation
Detrusor overactivity (neurogenic): failed trials of two medications from antimuscarinic or beta-adrenergic classes
Document two distinct medication trials each ≥1 month with agents named (e.g., darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium, mirabegron) and absence of current untreated UTI
Overactive bladder (OAB): failed trials of two medications from antimuscarinic and/or beta-adrenergic classes
Document two distinct medication trials each ≥1 month with agents named (e.g., darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium, mirabegron) and absence of current untreated UTI
Severe palmar/axillary hyperhidrosis: failed topical therapy and iontophoresis
Document ≥1 month topical trial (e.g., aluminum chloride) and trial of iontophoresis; note complications or ADL impact if present

Dosing principle	Provider action / documentation
Dosing must be individualized based on size, number, and location of muscles involved
Document muscles targeted, per‑site and total units planned, and rationale relating to size/number/location
Consider severity, presence of local muscle weakness, and prior response or adverse events when selecting dose
Document baseline functional status, presence of local weakness, prior treatment response or adverse events, and how these informed dosing selection

Policy preference	What to document
Plan encourages use of more cost‑effective options first where applicable and appropriate
When applicable, document prior use of lower‑cost alternatives or reasons why such options are not suitable for the member (clinical contraindication, intolerance, or prior failure)

Vial, Unit, and Quantity Limits

Botox vial and unit examples and limits by indication

100‑unit vial (common limit)Botox 100‑unit powder for injection: 1 vial per 84 days (general); 5 vials once for Ventral Hernia

200‑unit vial limitBotox 200‑unit powder for injection: 2 vials per 84 days

Ventral hernia single‑use exampleVentral Hernia: up to 500 Units (example shown as 5 × 100‑unit vials once preoperatively)

Billing unit referenceHCPCS unit billing used for indication‑specific unit limits (see dosing limits table)

onabotulinumtoxinA (Botox) — <= 400 Units maximum adult cumulative dose

General cumulative capDo not exceed 400 Units per 12 weeks for adults (unless otherwise specified)

Administration Sites and Technique

Note

Follow site‑specific injection techniques for office procedures

Injectable procedures described in the policy include intramuscular, intradermal, intraparotid, and detrusor injections; follow site‑specific technique recommendations (e.g., EMG, nerve stimulation, ultrasound guidance where referenced).

Procedure types include IM, ID, intraparotid, and detrusor injections
Use recommended localization techniques as appropriate for the site and patient (e.g., EMG, ultrasound)

OpenPayer

Botox (onabotulinumtoxinA) coverage

Coverage and Medical Necessity Criteria

Billing Codes, Units, and Coding Rules

Prior Authorization, Documentation, and Provider Requirements

Background and Definitions

Initial Therapy Requirements

Renewal and Continuation Requirements

Step Therapy and Prior Treatment Requirements

Vial, Unit, and Quantity Limits

Administration Sites and Technique