Botulinum Toxins
Defines medical necessity, investigational uses, authorization durations, and coding for multiple botulinum toxin products and indications for Premera Blue Cross providers and members.
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 was added to the investigational statement.
Criteria updated to state botulinum toxin products are not used concurrently for the treatment of the same condition and specific nonconcurrent rules for several product pairs.
Raynaud's phenomenon added to investigational statement.
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; definition of physical functional impairment aligned with Policy 10.01.514.
Clarified that non-formulary exception review authorizations for all drugs listed may be approved up to 12 months and that medications are subject to FDA dosing and administration information.
Updated concurrent-use restrictions: Botox, Daxxify, Dysport, Myobloc, and Xeomin are not used concurrently for treatment of cervical dystonia; similar concurrency restrictions added across other indications and products.
Letybo (letibotulinumtoxinA-wlbg) listed as cosmetic and not covered.
Clarified that use of Xeomin for treatment of upper facial lines is cosmetic and not covered.
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