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 state that botulinum toxin injections are only covered for certain indications: 
 
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 three 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 two 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 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 
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.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. 
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 ones quality of life and cannot be 
managed adequately with topical agents. 
 
These rules are found 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.