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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 say Indications: 
 
Spasticity 
 
Botulinum toxin can be used to reduce spasticity or excessive muscular contractions, to relieve pain, to assist 
with posture and walking, to improve range of motion, to enhance the effectiveness of physical therapy, and to 
reduce severe spasm to allow better perineal hygiene in patients with spasticity secondary to spastic hemiplegia 
and hemiparesis. 
 
Organic writers cramp is uncommon, and so Botulinum toxin for the treatment of organic writers cramp 
should be infrequent. 
 
Botulinum toxin is indicated for disorders associated with spastic conditions as above and dystonia. Please 
note: covered spastic conditions are listed in Article A52848 under "ICD-10-CM Codes that Support Medical 
Necessity." The wide range of Botulinum toxin dosages used in a treatment session is determined by patient 
age, degree of spasticity, number of injections made into each muscle and number of muscles treated. 
 
Electromyography or muscle stimulation, rather than site pain or tenderness, to determine injection site(s) for 
Botulinum toxin may be necessary, especially for spastic conditions of the face, neck and upper extremity. 
 
OnabotulinumtoxinA is indicated for the treatment of lower limb spasticity in adult patients to decrease the 
severity of increased muscle tone in ankle and toe flexors (gastrocnemius, soleus, tibialis posterior, flexor 
hallucis longus, and flexor digitorum longus). 
 
AbobotulinumtoxinA is indicated for the treatment of lower limb spasticity in adults. 
 
Blepharospasm 
 
Botulinum toxin injection therapy is accepted first line treatment for patients with blepharospasm and/or 
hemifacial spasm. If the upper and lower lid of the same eye and/or adjacent facial muscles, or brow are 
injected at the same surgery, the procedure is considered to be unilateral. Bilateral procedures will only be 
considered when both eyes or both sides of the face are injected.  
Achalasia 
 
Botulinum toxin for achalasia may be considered for the patient who has not responded satisfactorily to 
conventional therapy; is at high risk of complication from pneumatic dilation or surgical myotomy; has had 
treatment failure with pneumatic dilation or surgical myotomy; had perforation from pneumatic dilation; has an 
epiphrenic diverticulum or hiatal hernia; or has esophageal varices. 
 
Anal Fissure 
 
Botulinum toxin for chronic anal fissure may be considered for the patient who has not responded satisfactorily 
to conventional therapy. 
 
Hyperhidrosis 
 
OnabotulinumtoxinA has been approved by the Federal Drug Administration (FDA) for treatment of severe 
primary axillary hyperhidrosis (primary focal hyperhidrosis) that is inadequately managed with topical therapy. 
Compendia list onabotulinumtoxinA and rimabotulinumtoxinB as acceptable off-label agents for this condition. 
The definition of primary focal hyperhidrosis is severe sweating, beyond physiological needs; focal, visible, 
severe sweating of at least six (6) months duration without apparent cause with at least two (2) of the following 
characteristics: bilateral and relatively symmetric, significant impairment in daily activities, age of onset less 
than 25 years, positive family history, and cessation of focal sweating during sleep. 
 
Sialorrhea 
 
The treatment of sialorrhea due to conditions such as motor neuron disease or Parkinson's disease in those 
patients who have failed to respond to a reasonable trial of traditional therapies (eg., anticholinergics and 
speech therapy) or who have a contraindication to or cannot tolerate anticholinergic therapy, will be allowed 
for coverage. 
 
Urinary Incontinence 
 
Urinary incontinence due to neurogenic detrusor overactivity (NDO) commonly occurs in patients with spinal 
cord injuries (SCI) or neurological diseases such as multiple sclerosis (MS). Patients with NDO usually use 
clean intermittent self-catheterization (CIC) to empty the bladder. When incontinence episodes occur between 
catheterizations, oral anticholinergic agents are used to decrease bladder contractility and improve 
incontinence.  
 
OnabotulinumtoxinA is indicated for the treatment of overactive bladder (OAB) with symptoms of urge urinary 
incontinence, urgency, and frequency, in adults and patients five years of age and older who have an 
inadequate response to or are intolerant of an anticholinergic medication. 
 
Headache/Migraine 
 
Coverage will only be allowed for those patients with chronic daily headaches (headache disorders occurring 
greater than 15 days a month - in many cases daily with a duration of four or more hours - for a period of at 
least 3 months) who have significant disability due to the headaches, and have been refractory to standard and 
usual conventional therapy. The etiology of the chronic daily headache may be chronic tension-type headache 
or chronic migraine (CM). CM is characterized by headache on > 15 days per month, of which at least 8 
headache days per month meet criteria for migraine without aura or respond to migraine-specific treatment. For 
continuing Botulism toxin therapy the patients must demonstrate a significant decrease in the number and 
frequency of headaches and an improvement in function upon receiving Botulinum toxin.  
Limitations: 
 
Medicare will allow payment for one injection per site regardless of the number of injections made into the site. 
A site is defined as one eye (including all muscles surrounding the eye including both upper and lower lids); 
one side of the face; the neck; or extremity and/or trunk muscle(s). 
 
Failure of two definitive, consecutive, treatment sessions involving a muscle or group of muscles could 
preclude further coverage of the serotype used in the treatment for a period of one year after the second session. 
It may be reasonable, however, to attempt treatment with a different serotype. 
 
Treatment of wrinkles using Botulinum toxins is considered to be cosmetic, and is not covered under Medicare. 
 
Payment will not be made for any spastic condition of smooth muscle, such as spastic colon and biliary 
dyskinesia, or of any spastic condition not listed under ICD-10-CM Codes That Support Medical Necessity 
in Article A52848. 
 
The cost of special syringes is not separately payable. They are considered part of the surgical procedure. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Botulinum Toxins 
(L33646). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.