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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. 
 
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.  
 
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. 
 
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. 
 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. 
 
Botulinum toxin for chronic anal fissure may be considered for the patient who has not responded satisfactorily 
to conventional therapy. 
 
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. 
 
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 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. 
 
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. 
 
You can find these rules in Local Coverage Determination (LCD) Botulinum Toxins (L33646). 
 
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.