CurrentUnitedHealthcarePolicy CSIND0017.08

Botulinum Toxins A and B (for Indiana Only)

Medical benefit drug policy governing coverage and medical necessity criteria for botulinum toxin products (A and B) for members in Indiana, including FDA-approved indications and use of InterQual criteria; affects providers requesting coverage for these agents in Indiana.

Policy Summary

PayerUnitedHealthcare

PolicyBotulinum Toxins A and B (for Indiana Only)

Policy CodePolicy CSIND0017.08

Change TypeMaterial — codes removed

Effective DateFeb 1, 2026

Next Review Date

Key ActionFollow InterQual criteria for Botox, Dysport, Myobloc, and Xeomin; document diagnosis and symptom criteria for Daxxify to support prior authorization.

SourceLink

POLICY UPDATE CHANGES

Removed ICD-10 diagnosis codes G24.09, G24.1, G24.2, G24.4, G24.5, G24.8, and G24.9 from Applicable Codes.

5botulinum products listed

1state-specific (Indiana)

1FDA indication called out

1TWSTRS thresholds noted

Coverage and Medical Necessity Criteria

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inv-01: Daxxify (daxibotulinumtoxinA-lanm) — Initial Therapy

Covered when ALL of the following are met

Daxxify for cervical dystonia: Diagnosis of cervical dystonia (spasmodic torticollis).

Daxxify is FDA-approved for treatment of cervical dystonia in adults.

Daxxify symptom requirements: Symptoms include both: (1) sustained head tilt or abnormal posturing resulting in pain and/or functional impairment; and (2) recurrent involuntary contraction of one or more neck muscles (e.g., sternocleidomastoid, splenius, trapezius, posterior cervical).

Clinical trial entry required baseline TWSTRS thresholds; prior botulinum toxin patients in trial required ≥14 weeks since last administration.

inv-02: Botox, Dysport, Myobloc, Xeomin — Coverage aligned with InterQual

Covered when InterQual criteria are met

Other listed botulinum toxins: Use InterQual Specialty Rx Non-Oncology criteria to determine medical necessity for onabotulinumtoxinA (Botox), abobotulinumtoxinA (Dysport), rimabotulinumtoxinB (Myobloc), and incobotulinumtoxinA (Xeomin) for the specific condition being treated.

Refer to the current release of the InterQual guideline for condition-specific clinical coverage criteria.

Effective 02/01/2026, the Applicable Codes list for this policy was revised. The revision removed the following ICD-10 diagnosis codes from the policy: G24.09, G24.1, G24.2, G24.4, G24.5, G24.8, and G24.9.

Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by applicable federal, state, or contractual requirements and laws; inclusion of a code does not guarantee reimbursement or claim payment and other policies or guidelines may apply.

Procedure and Diagnosis Codes

HCPCS / J-codesHCPCS

J0585	Injection, onabotulinumtoxinA, 1 unit.
J0586	Injection, abobotulinumtoxinA, 5 units.
J0587	Injection, rimabotulinumtoxinB, 100 units.
J0588	Injection, incobotulinumtoxinA, 1 unit.
J0589	Injection, daxibotulinumtoxina-lanm, 1 unit.

Diagnosis (ICD-10)ICD-10

G24.3

Spasmodic torticollis

HCPCS / J-codesHCPCS

J0585	Injection, onabotulinumtoxinA, 1 unit.
J0586	Injection, abobotulinumtoxinA, 5 units.
J0587	Injection, rimabotulinumtoxinB, 100 units.
J0588	Injection, incobotulinumtoxinA, 1 unit.
J0589	Injection, daxibotulinumtoxina-lanm, 1 unit.

Diagnosis (ICD-10)ICD-10

G24.3

Spasmodic torticollis

TWSTRS baseline minimums (trial entry)

TWSTRS baseline minimums (trial entry)Total score ≥ 20; severity score ≥ 15; disability score ≥ 3; pain score ≥ 1

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for the botulinum toxin products listed in this policy (Botox, Dysport, Myobloc, Xeomin, and Daxxify). Providers must obtain prior authorization per UnitedHealthcare processes before administering these agents.

Affected products: Botox (onabotulinumtoxinA), Dysport (abobotulinumtoxinA), Myobloc (rimabotulinumtoxinB), Xeomin (incobotulinumtoxinA), Daxxify (daxibotulinumtoxinA-lanm)

Note

Follow InterQual Criteria for Botox/Dysport/Myobloc/Xeomin

Providers should follow the current InterQual® criteria for medical necessity determinations when requesting coverage for Botox, Dysport, Myobloc, and Xeomin. For these products, clinical coverage criteria and required documentation are defined in the InterQual Specialty Rx Non-Oncology guidelines referenced in this policy.

Follow InterQual®: Botox — OnabotulinumtoxinA (Botox) guideline
Follow InterQual®: Dysport — AbobotulinumtoxinA (Dysport) guideline
Follow InterQual®: Myobloc — RimabotulinumtoxinB (Myobloc) guideline
Follow InterQual®: Xeomin — IncobotulinumtoxinA (Xeomin) guideline

Documentation Required

Documentation Required for Daxxify (Cervical Dystonia)

For Daxxify requests for cervical dystonia, documentation must support the diagnosis of cervical dystonia and the presence of symptomatic findings. Specifically document: sustained head tilt or abnormal posturing resulting in pain and/or functional impairment, and recurrent involuntary contraction of one or more neck muscles (for example, sternocleidomastoid, splenius, trapezius, posterior cervical).

Confirm clinical diagnosis of cervical dystonia (spasmodic torticollis)
Document symptoms: sustained head tilt or abnormal posturing causing pain and/or functional impairment
Document recurrent involuntary contraction of one or more neck muscles (e.g., sternocleidomastoid, splenius, trapezius, posterior cervical)

Note

Coding Reference — Inclusion Does Not Imply Coverage

Listing of a code in this policy is for reference only and does not by itself indicate coverage, guarantee reimbursement, or override federal, state, or contractual requirements that determine benefit coverage.

Inclusion of a code does not imply the service is a covered or non-covered health service
Benefit coverage is determined by federal, state, or contractual requirements and applicable law
Inclusion of a code does not guarantee claim payment or reimbursement

Daxxify Initial Therapy Criteria

inv-14: Daxxify initial therapy — Daxxify-specific initial coverage criteria

Daxxify-specific initial coverage criteria

Daxxify initial criteria: Diagnosis of cervical dystonia AND symptoms including both sustained head tilt/abnormal posturing causing pain or functional impairment AND recurrent involuntary contraction of one or more neck muscles.TWSTRS baseline thresholds in trial: total ≥ 20; severity ≥ 15; disability ≥ 3; pain ≥ 1

In the pivotal trial, patients who previously received a botulinum toxin were required to have ≥ 14 weeks since the most recent administration.

Clinical Background

Cervical dystonia (spasmodic torticollis) is characterized by sustained head tilt or abnormal posturing and recurrent involuntary contractions of neck muscles that can produce pain and functional impairment. Botulinum toxin products (types A and B) are used to reduce pathological muscle overactivity. Daxxify (daxibotulinumtoxinA-lanm) is FDA-approved for non-cosmetic treatment of cervical dystonia in adults and demonstrated efficacy in randomized trials that used the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) as a primary outcome measure.

OpenPayer