Appeal type: unknown
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 say that Botox for 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
2
: 
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 > 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
2
: 
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 You can find this rule at Local Coverage Determination (LCD) L34635: Botulinum Toxin Type A & Type B 
(eff. 11/14/21). 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
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. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 99 of the 2022 Evidence of Coverage (EOC).