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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
 
Chemodenervation techniques are indicated/covered for: 
1. Chemodenervation of muscle innervated by the facial nerve in the management of blepharospasm or 
hemifacial spasm 
2. Chemodenervation of cervical spinal muscles in the management of spasmodic torticollis 
3. Chemodenervation of extremity muscles in the management of dystonias, cerebral palsy, upper and lower 
limb spasticity (see Note:) and multiple sclerosis 
4. Chemodenervation of extraocular muscles in the management of strabismus 
5. Chemodenervation of the lower esophageal sphincter in the management of achalasia  
6. Chemodenervation of laryngeal muscles in the treatment of adductor spasmodic dysphonia  
7. Chemodenervation of bilateral frontalis, trapezius, temporalis, sternocleidomastoid, and splenius capitis 
muscles for treatment of chronic tension headache and intractable daily headache 
8. Chemodenervation of procerus and bilateral frontalis, corrugator, occipitalis, temporalis, trapezius, and 
cervical paraspinal muscle group for the prophylaxis of headaches in adult patients with chronic migraine (&#8805; 15 
days per month with headache lasting 4 hours a day or longer) 
9. Chemodenervation of sweat glands for the treatment of severe primary hyperhidrosis that is inadequately 
managed with topical agents. Severe is defined for this purpose as level 3 (sweating barely tolerable/frequently 
interferes with daily activity) or level 4 (sweating intolerable/always interferes with daily activities) on the 
Hyperhidrosis Disease Severity Scale (HDSS). 
10. Chemodenervation of the internal anal sphincter for the treatment of chronic anal fissure 
11. Chemodenervation of the detrusor urinae muscle for the treatment of over activity associated with a 
neurologic condition in adults with an inadequate response to anticholinergic treatment and for the treatment of 
overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and frequency, in adults who 
have an inadequate response to or are intolerant of an anticholinergic medication  
12. Chemodenervation of the parotid and submandibular salivary glands, bilaterally 
 
Services performed for excessive frequency are not medically necessary. Frequency is considered excessive 
when services are performed more frequently than generally accepted by peers, and the reason for additional 
services is not justified by documentation. 
 
You can find this rule in the Local Coverage Determination (LCD): Botulinum Toxins (L33646) effective 
October 31, 2019. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.