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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 approved indications for botulinum toxin type A and toxin type B differ. WPS GHA has 
determined that the separate accepted indications for the botulinum toxin products will be combined into a 
single list of covered indications in this Local Coverage Determination (LCD). It is the responsibility of 
providers to use each drug in accordance with approved indications. While this policy contains a single list of 
covered indications, this is not meant to imply that botulinum toxin products are interchangeable. 
 
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. Since organic writer's cramp is uncommon, Medicare 
would not expect to see the treatment of this condition to be billed frequently. 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. It is usually considered not 
medically necessary to give botulinum toxin injections for spastic conditions more frequently than every 12 
weeks. 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.  
Botulinum toxin may be covered in the treatment of achalasia. According to the 2018 ISDE achalasia guidelines, botulinum injections should mainly be used in patients 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 
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.2. Treatment of chronic migraines 
will be covered when they meet the following diagnostic criteria: for migraine with aura and /or criteria for 
migraine without aura. Treatment with botulinum toxin may be given every 12 weeks as multiple injections 
around the head and neck. You can find this information in Medicare's 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.