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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. 
 
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise 
reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs used for 
indications other than what is indicated on the official label may be covered if the use is determined to be 
medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or 
accepted standards of medical practice. 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, Sections 
50.4.1 and 50.4.2. 
 
The rules say that: 
 
1. 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, non-covered by Medicare. 
2. Since organic writer's cramp is uncommon, Medicare would not expect to see the treatment of this 
condition to be billed frequently. 
3. 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 3 months at which time the patient may require repeat injections to control the spastic or 
excessive muscular condition.  
4. It is usually considered not medically necessary to give botulinum toxin injections for spastic conditions 
more frequently than every 12 weeks. 
5. Coverage of treatments provided may be continued unless any 2 treatments in a row, utilizing an 
appropriate or maximum dose of botulinum toxin failed to produce satisfactory clinical response.  
6. Botulinum toxin may be covered in the treatment of achalasia. According to the 2018 ISDE achalasia 
guidelines, botulinum injections should mainly be used in patient's age 50 or greater and for patients that are unfit for surgery or as a bridge to more definitive therapies such as surgery or balloon dilatation.1 
7. Chronic migraine is defined as a "headache occurring on 15 or more days a month for more than three 
months, which, on at least eight days/month has the features of migraine headache." Treatment with botulinum 
toxin may be given every 12 weeks as multiple injections around the head and neck. 
8. Botulinum toxin for chronic anal fissure may be considered for the patient who has not responded 
satisfactorily to conservative treatment. Conservative treatment may include the use of bulking agents, sitz 
baths or topical agents. 
9. Botulinum toxin is covered for hyperhidrosis that significantly affects one's quality of life and cannot be 
managed adequately with topical agents. 
 
You can find this information in the Local Coverage Determination (LCD): Botulinum Toxin Type A & Type 
B (L34635). 
 
The rules say that payment will not be made for any spastic condition not listed under Codes That Support 
Medical Necessity such as: 
 
1. Use of botulinum toxin for the treatment of irritable colon, biliary dyskinesia, headaches, craniofacial 
wrinkles or any treatment of other spastic conditions not listed as covered in this policy are considered to be 
experimental (including the treatment of smooth muscle spasm). 
2. Use of botulinum toxin for patients receiving aminoglycosides, which may interfere with 
neuromuscular transmission; or 
3. Use of botulinum toxin for patients with chronic paralytic strabismus, except to reduce antagonistic 
contractor in conjunction with surgical repair. 
4. Treatment exceeding accepted dosage parameters unless supported by individual medical record review 
as well as treatments where the goal is to improve appearance rather than function. 
5. The corresponding surgery code was not billed. 
 
You can find this information in the Local Coverage Article: Billing and Coding: Botulinum Toxin Type A & 
Type B (A57474). 
 
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.