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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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. The rules also stat that 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) Note: Onabotulinamtoxin A (BOTOX), is the only botulinum toxin product that is Food and Drug Administration (FDA)-approved 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 You can find this rule at Local Coverage Determination (LCD): Chemodenervation (L33458).
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.