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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 that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say Covered Indications: NOTE: The four botulinum therapies are not interchangeable and are only covered as listed below. Botulinum toxins (Botox, Dysport, Xeomin and Myobloc), will be considered medically reasonable and necessary when administered for treatment of FDA-labeled indications and Off-label indications (as applicable) below: FDA3 indications for onabotulinumtoxinA (Botox) as noted on the FDA website: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=103000 Off-Label indications for onabotulinumtoxinA (Botox) may be considered medically reasonable and necessary in patients for the following conditions: Esophageal achalasia in adults who are considered poor surgical candidates4 Chronic anal fissure for patients with inadequate response to conservative or pharmacologic treatment5 Essential hand tremor for patients with a high amplitude tremor that disrupts activities of daily living and have had inadequate response to oral pharmacotherapy such as propranolol and primidone6 Focal limb dystonia6 Hemifacial spasm in adults (cranial nerve VII disorder)6 Isolated oromandibular dystonia in adults7 Laryngeal dystonia (spastic dysphonia) for adductor type (ADSD)6 Bothersome simple motor tics in adolescents and adults when the benefits of treatment outweigh the risks8 Severely disabling or aggressive vocal tics in older adolescents and adults when the benefits of treatment outweigh the risks8 FDA9 indications for abobotulinumtoxinA (Dysport) as noted on the FDA website: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=125274 Off-label indications for abobotulinumtoxinA (Dysport) may be considered medically reasonable and necessary in patients for the following conditions: Blepharospasm in adults6,7 Hemifacial spasm in adults (cranial nerve VII disorder)6 Isolated oromandibular dystonia in adults7 FDA10 indications for incobotulinumtoxinA (Xeomin) as noted on the FDA website: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=125360 FDA11 indications for rimabotulinumtoxinB (Myobloc) as noted on the FDA website: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=103846 Limitations Localization procedures would not be expected for easily targeted muscles and, therefore, would not be considered medically reasonable and necessary.7 Cosmetic procedures are not a covered benefit under Medicare. Treatment of wrinkles, also referred to as glabellar lines, smoker's lines, crow's feet, laugh lines and aging neck, using botulinum toxins is considered to be a cosmetic procedure, and is not covered under Medicare.
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. You can find this information in Medicare's Local Coverage Determination (LCD): Botulinum Toxins (L38809).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.