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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 Botulinum toxins (Botox, Dysport, Xeomin and Myobloc), will be considered 
medically reasonable and necessary when administered for treatment of the following FDA-labeled indications 
and other indications as specified below: 
 
FDA Indications for Botox: 
&#61623; strabismus and blepharospasm associated with dystonia  
&#61623; benign essential blepharospasm  
&#61623; facial nerve (cranial nerve VII) disorders in patients 12 years of age and older 
&#61623; cervical dystonia to reduce the severity of abnormal head position and neck pain (i.e., spasmodic 
torticollis) 
&#61623; severe primary axillary hyperhidrosis inadequately managed with topical agents. Patients should be 
evaluated for potential causes of secondary hyperhidrosis (e.g., hyperthyroidism) to avoid symptomatic 
treatment of hyperhidrosis without the diagnosis and/or treatment of the underlying disease. 
&#61623; upper limb spasticity in adult patients, to decrease the severity of increased muscle tone in elbow 
flexors (biceps), wrist flexors (flexor carpi radialis and flexor carpi ulnaris) and finger flexors (flexor 
digitorum profundus and flexor digitorum sublimis). 
&#61623; prophylaxis of headaches in adult patients with chronic migraine (> 15 days per month with headache 
lasting 4 hours a day or longer). 
&#61623; Treatment of urinary incontinence due to detrusor overactivity associated with a neurologic condition 
[e.g., spinal cord injury (SCI), multiple sclerosis (MS)] in adults who have an inadequate response to or 
are intolerant of anticholinergic medication. 
&#61623; 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. 
&#61623; Lower limb spasticity in adult patients to decrease the severity of lower limb spasticity (i.e., increased 
muscle tone) in ankle and toe flexors (gastrocnemius, soleus, tibialis posterior, flexor hallucis longus, 
and flexor digitorum longus):  
o spastic hemiplegia 
o spasticity related to stroke 
Off-label Indications for Botox: 
Botox is used for a wide range of off-label uses. The use of Botox may be considered a medically necessary 
off-label indication for the treatment of dystonia or lower limb spasticity resulting in functional impairment 
(interference with joint function, mobility) and/or pain in patients with any of the following hereditary, 
acquired, degenerative, or demyelinating diseases of the central nervous system: 
 
&#61623; dynamic muscle contracture in pediatric or adult cerebral palsy patients 
&#61623; synkinetic closure of the eyelid associated with VII cranial nerve aberrant regeneration (e.g., hemi facial 
spasm) 
&#61623; idiopathic torsion dystonia 
&#61623; symptomatic torsion dystonia 
&#61623; oromandibular dystonia 
&#61623; spasmodic dysphonia 
&#61623; orofacial dyskinesia 
&#61623; focal hand dystonia (e.g., writer's cramp) 
&#61623; hereditary spastic paraplegia 
&#61623; neuromyelitis optica 
&#61623; Schilder's disease 
The use of Botox may be considered medically necessary in patients with laryngeal spasm and torticollis 
(whether congenital, due to child birth injury, or traumatic). 
The use of Botox may be considered medically necessary in patients with achalasia who have not responded 
to dilation therapy or who are considered poor surgical candidates. 
The use of Botox may be considered medically necessary as treatment of chronic anal fissure. 
Treatment of gustatory hyperhidrosis (secondary) with Botox may be considered medically necessary in 
patients with medical complications; such as skin maceration with secondary infections, or significant 
functional impairments. 
You can find this rule in the Local Coverage Determination (LCD): Botulinum Toxins (L33274). 
 
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.