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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 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, smokers lines, crows feet, laugh lines and aging 
neck, using botulinum toxins is considered to be a cosmetic procedure, and is not covered under Medicare. 
 
You can find this information in the Local Coverage Determination (LCD) Botulinum Toxins L33274. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.