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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 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. 
1. 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. 
2. Since organic writer's cramp is uncommon, Medicare would not expect to see the treatment of this 
condition to be billed frequently. 
3. 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.  
4. It is usually considered not medically necessary to give botulinum toxin injections for spastic conditions 
more frequently than every 12 weeks. 
5. 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.  6. Botulinum toxin may be covered in the treatment of achalasia. According to the 2018 ISDE achalasia 
guidelines, botulinum injections should mainly be used in patients age 50 or greater and for patients that 
are unfit for surgery or as a bridge to more definitive therapies such as surgery or balloon dilatation.
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7. Chronic migraine is defined as a headache occurring on 15 or more days a month for more than three 
months, which, on at least eight days/month has the features of migraine headache. Treatment of chronic 
migraines will be covered when they meet the following diagnostic criteria: for migraine with aura and /or 
criteria for migraine without aura. Treatment with botulinum toxin may be given every 12 weeks as 
multiple injections around the head and neck.  
A. Migraine with aura: 
1. At least two attacks fulfilling the following criteria a and b  
a. One or more of the following fully reversible aura symptoms  
o Visual (aura, changes in vision) 
o sensory (e.g., tingling in hands or face, pins and needles, numbness 
o speech and/or language difficulties 
o motor (e.g., weakness) 
o brainstem (e.g., vertigo, tinnitus, loss of hearing, diploplia, ataxia not 
attributable to sensory deficit, and decreased level of consciousness) 
o retinal (visual disturbance, flash of light, blind spot) 
b. At least three of the following six characteristics:  
o at least one aura symptom spreads gradually over greater than 5 minutes 
o two or more aura symptoms occur in succession 
o each individual aura symptoms last 5-60 minutes 
o at least one aura symptom is unilateral 
o at least one aura symptom is positive 
o the arura is accompanied, or followed within 60 minutes, by headache 
B. Migraine without aura:  
1. At least five attacks fulfilling the following criteria  
a. Headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated) 
b. Headache has at least two of the following:  
o unilateral location 
o pulsating quality 
o moderate or severe pain intensity 
o aggravation by or causing avoidance of routine physical activity (e.g. walking 
or climbing stairs) 
c. During headache at least one of the following:  
o nausea and/or vomiting 
o photophobia and phonophobia 
8. Botulinum toxin for chronic anal fissure may be considered for the patient who has not responded 
satisfactorily to conservative treatment. Conservative treatment may include the use of bulking agents, sitz 
baths or topical agents. 
9. Botulinum toxin is covered for hyperhidrosis that significantly affects ones quality of life and cannot be 
managed adequately with topical agents. 
You can find this rule in the Local Coverage Determination (LCD) for Botulinum Toxin Type A & Type B, 
L34635. 
 
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.