Appeal type: unknown
Decision: unknown

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 say 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 (e.g. Hemifacial spasm, dystonia and spasticity), smooth muscles (e.g. Detrusor over activity and achalasia), glands (e.g. Sialorrhoea and hyperhidrosis) and additional conditions that are being investigated. Although botulinum toxins have only been FDA-approved for limited uses, they are frequently used off-label as well. A patient who is not responsive or who ceases to respond to one serotype may respond to the other. You can find this rule in the Local Coverage Determination (LCD) - Botulinum Toxin Type A & Type B (L34635) - Effective November 26, 2020. The rules say that 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 (e.g., cerebral palsy, stroke, head trauma, spinal cord injuries, and multiple sclerosis) will be limited to those conditions listed in the Billing and Coding: Botulinum Toxin Type A & B (A57474). 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. The site description is included in the CPT code description. Payment will be based on the Medicare Physician Fee Schedule and National Correct Coding Initiative. 8. Botulinum toxin may be covered in the treatment of achalasia. This use appears to be safe and effective. Two-thirds of patients respond within six months of treatment and effectiveness lasts an average of more than one year for the initial treatment, although shorter and longer durations have been reported. The use of botulinum toxin should not be endorsed for all patients, but it can be considered individually if: a. The patient has failed conventional therapy; b. The patient is at high risk of complications of pneumatic dilation or surgical myotomy; c. The patient has failed a prior myotomy or dilation; d. The patient has had a previous dilation-induced perforation; e. The patient has an epiphrenic diverticulum or hiatal hernia, both of which increase the risk of dilation-induced perforation. 9. Migraine headaches are described as an intense pulsing or throbbing pain in one area of the head. The headaches are often accompanied by nausea, vomiting, and sensitivity to light and sound. Migraine usually begins with intermittent headache attacks 14 days or fewer each month (episodic migraine), but some patients go on to develop the more disabling chronic migraine. 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 this rule in the Local Coverage Determination (LCD) - Botulinum Toxin Type A & Type B (L34635) - Effective November 26, 2020.
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.