Botulinum Toxins (Medical Policy)
Medical necessity and coverage criteria for botulinum toxin products (e.g., Botox, Dysport, Xeomin, Myobloc, Daxxify) for various neurologic, urologic, gastrointestinal, dermatologic, and other indications for Premera Bluecross members.
Updated the note that use is considered cosmetic when the primary purpose is to preserve or improve appearance in the absence of a physical functional impairment.
Raynaud's phenomenon added to investigational statement.
Updated criteria to state certain botulinum products are not used concurrently for treatment of same condition (various combinations listed).
Added Daxxify coverage for cervical dystonia and Daxxify cosmetic not covered previously; labeling Daxxify as cosmetic in earlier change.
Clarified that non-formulary exception review authorizations for all drugs listed in this policy may be approved up to 12 months.
Clarified that the medications listed in this policy are subject to the product's FDA dosage and administration prescribing information.
Updated criteria to state Botox, Daxxify, Dysport, Myobloc, and Xeomin are not used concurrently for the treatment of cervical dystonia and other listed conditions.
Updated note that use is considered cosmetic when the primary purpose is to preserve or improve appearance in the absence of a physical functional impairment.
Raynaud's phenomenon added to investigational statement.
Added Letybo (letibotulinumtoxinA-wlbg) listed as cosmetic and not covered.
Clarified that use of Xeomin for the treatment of upper facial lines is considered cosmetic and not covered.
Added and removed various CPT/HCPCS code updates across 2023-2024 (e.g., CPT 64650, 64653, 43236; HCPCS C9160, J0589).
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