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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 state that Botulinum toxins are potent neuromuscular blocking agents that are useful in treating 
various focal muscle spastic disorders and excessive muscle contractions, such as dystonia, spasms, and 
twitches. They produce a presynaptic neuromuscular blockade by preventing the release of acetylcholine from 
the nerve endings. Since the resulting chemical denervation of muscle produces local paresis or paralysis, 
selected muscles can be treated. Botulinum toxins are used in the treatment of overactive skeletal muscles (e.g., 
Hemifacial spasm, dystonia and spasticity), smooth muscles (e.g., Detrusor overactivity and achalasia), glands 
(e.g., Sialorrhoea and hyperhidrosis) and additional conditions that are being investigated. 
 
Limitations 
Voluntary muscular contraction depends upon the release of acetylcholine from vesicles within a nerve ending 
following stimulation of the nerve. The acetylcholine is released into the neuromuscular junction, binding to 
specific proteins called receptors in the membrane of the muscle fiber. The effect of the acetylcholine at these 
receptors is to cause the muscle to contract. When a sufficient amount of acetylcholine has been released with 
subsequent binding to the muscle fiber proteins, muscle contraction occurs. Botulinum toxin type A and 
botulinum toxin type B create a chemical blockade by inhibiting the release of acetylcholine from the nerve 
ending vesicles thereby preventing the acetylcholine from binding to the proteins in the receptor site on the 
muscle. Localized weakness or paralysis occurs in the muscle injected with botulinum toxin. 
 
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 three 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 two treatments in a row, utilizing an 
appropriate or maximum dose of botulinum toxin failed to produce satisfactory clinical response. You can find 
this rule in the Medicare Local Coverage Determination (LCD)- L34635, Botulinum Toxin Type A & Type B. 
 
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.