Initial PA 6 months; renewals 12 months; age ≥18

Prior authorization is required. Initial prior authorization validity will be provided for 6 months (180 days); standard renewals may be issued every 12 months (365 days) thereafter. Members must generally be at least 18 years of age unless an indication specifies a different minimum age (see indication-specific criteria).

PA required; bill with HCPCS J0586

Prior authorization is required for Dysport administration. Claims/billing should use HCPCS code J0586 (Injection, abobotulinumtoxina, 5 units; 1 billable unit = 5 units) and must conform to the policy's dosing limits and intervals for the indicated condition.

NQTL factors considered for PA

Prior authorization was applied after assessing Non‑Quantitative Treatment Limitation (NQTL) factors including the clinical indication, safety and efficacy, potential for misuse/abuse, and drug cost; these factors informed the decision to require PA.

• NQTL factors considered: Indication (Yes), Safety/efficacy (Yes), Potential for misuse/abuse (No), Cost (Yes)

Follow CMS manuals and applicable NCDs/LCDs/LCAs

For Medicare beneficiaries, follow CMS guidance: the Medicare Benefit Policy Manual and any applicable National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs). Compliance with NCDs/LCDs/LCAs is required where applicable.

• Use CMS Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 as applicable.
• Search the CMS Coverage Database for relevant NCD/LCD/LCA documents.

Document required prior therapy trials and failures

Before approval, document trials and failures of required non‑surgical or pharmacologic therapies specific to the indication (examples provided by indication).

• Severe axillary hyperhidrosis: failed ≥1 month trial of a topical agent.
• Severe palmar hyperhidrosis: failed ≥1 month topical trial and failed iontophoresis.
• Chronic anal fissure: failed non‑pharmacologic measures and ≥1 month trial of conventional pharmacologic therapy.
• NDO/OAB: failed 1+ month trials of two medications from antimuscarinic or beta‑adrenergic classes.

Continue other prophylactic modalities for chronic migraine

For chronic migraine prophylaxis, continue other prophylactic interventions as part of ongoing management when administering Dysport.

• Examples: pharmacotherapy, behavioral therapy, neuromodulation, trigger avoidance, physical therapy.

No explicit step‑therapy algorithm in policy (NQTL assessed)

The policy considered NQTL factors (indication, safety/efficacy, cost) when requiring PA, but it does not prescribe a specific step‑therapy algorithm within the cited policy content.

Document baseline objective migraine severity (HIT‑6, MHD)

For chronic migraine prophylaxis PA requests, include baseline disease severity using an objective measure (e.g., HIT‑6 score or Monthly Headache Days) to document the need for therapy.

• Baseline objective measures: HIT‑6, monthly headache days (MHD), MIDAS, or MPFID.

Record baseline and post‑treatment outcomes with validated tools

Document baseline and post‑treatment outcomes using validated tools appropriate to the indication (examples include HIT‑6, MHD, MIDAS for migraine; Ashworth Scale for spasticity; CGI/Physician Global Assessment where applicable).

• Migraine: HIT‑6, MHD, MIDAS, MPFID and functional improvement.
• Spasticity: Ashworth Scale, CGI, or Physician Global Assessment showing decreased tone.
• Incontinence/OAB: documented change in incontinence frequency and periodic PVR assessment.

Follow cited CMS Local Coverage Articles for botulinum toxin billing

Providers should follow the cited Medicare Local Coverage Articles (LCAs) and billing/coding guidance for botulinum toxin injections when billing claims.

• Several LCAs are cited (see references) with effective date 04/09/2026 for billing/coding guidance.

Use covered ICD‑10 codes from Appendix 1 on claims

Use diagnosis codes listed in Appendix 1 for claims. Appendix 1 contains the covered ICD‑10 codes and examples (e.g., G43.* for chronic migraine, I69.* post‑cerebrovascular codes, K60.1 for chronic anal fissure).

• Appendix 1 lists covered ICD‑10 codes that should be used on claims for Dysport.

Denial risk: FDA‑labeled contraindications & concurrent botulinum toxin

Requests may be denied if the member has FDA‑labeled contraindications (e.g., hypersensitivity to any botulinum toxin product or excipients, hypersensitivity to cow's milk protein, active infection at the proposed injection site) or if the member is receiving concurrent treatment with another botulinum toxin.

Denial trigger: insufficient objective outcome documentation

Authorization requests lacking the policy‑specified objective outcome documentation for the condition (e.g., improvement in eyelid spasm for blepharospasm, reduction in monthly headache days or HIT‑6/MIDAS improvement for chronic migraine, validated spasticity scale improvement for spasticity) may be denied.

• Denials may be triggered by absence of documented symptomatic or objective improvement per indication‑specific response criteria.

PA consideration: indication, safety/efficacy, cost

Prior authorization may be applied because of the drug's indication, safety/efficacy considerations, and its cost, per the NQTL factor assessment.

Dual coding required for primary G/M diagnosis codes

Claims using primary G and M diagnosis codes without the required secondary G or I code may be denied; ensure dual‑coding requirements are met when submitting claims with primary G/M codes.

• Primary G and M codes require a secondary G or I code to be payable.