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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 state that the clinical indications for botulinum toxins have increased exponentially since first used two decades ago. They are used in the treatment of overactive skeletal muscles, smooth muscles, glands, and additional conditions that are being investigated. It is expected that physicians will be familiar with and experienced in the use of these agents and utilize evidence-based medicine to select the appropriate drug and dose regimen for each patient condition. Although botulinum toxins have only been Food & Drug Administration (FDA) approved for limited uses, they are frequently used off-label as well. Approved indications for botulinum toxin type A and toxin type B differ. The Medicare contractor has determined that the separate accepted indications for the botulinum toxin products will be combined into a single list of covered indications. It is the responsibility of providers, however, to use each drug in accordance with approved indications unless there are valid and documented reasons stating why the unapproved or unaccepted form is used. Before consideration of coverage may be made:
1. In most cases it should be established that the patient has been unresponsive to conventional methods of treatments such as medication, physical therapy and other methods used to control and/or treat spastic condition.
2. Coverage of botulinum toxin for certain spastic conditions will be limited to certain specified conditions. All other uses in the treatment of other types of spasm will be considered as investigational and therefore, noncovered by Medicare.
3. Since organic writer's cramp is uncommon, Medicare would not expect to see the treatment of this condition to be billed frequently.
4. The patient who has a spastic or excessive muscular contraction condition is usually started with a low dose of botulinum toxin. Other spastic or muscular contraction conditions, such as eye muscle disorders, (e.g., blepharospasm) may require lesser amounts of botulinum toxin. For larger muscle groups, it is generally agreed that once a maximum dose per site has been reached and there is no response, the treatment is discontinued. The treatments may be resumed at a later date. With response, the effect of the injections generally lasts for three months at which time the patient may require repeat injections to control the spastic or excessive muscular condition.
5. It is usually considered not medically necessary to give botulinum toxin injections for spastic conditions more frequently than every 90 days. There may be slight variation based on FDA indications for a particular product.
6. Coverage of treatments provided may be continued unless any two treatments in a row, utilizing an appropriate or maximum dose of botulinum toxin failed to produce satisfactory clinical response.
7. Medicare will allow payment for one injection per site regardless of the number of injections made into the site.
8. Botulinum toxin may be covered in the treatment of achalasia.
9. To treat chronic migraines, botulinum toxin is given approximately every 12 weeks as multiple injections around the head and neck to try to dull future headache symptoms. Botulinum toxin has not been shown to work for the treatment of migraine headaches that occur 14 days or less per month, or for other forms of headache.
10. Botulinum toxin for chronic anal fissure may be considered for the patient who has not responded satisfactorily to conventional therapy.

You can find these rules in Local Coverage Determination (LCD) Botulinum Toxin Type A & Type B (L34635). 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.