Transcription of Botulinum Toxins A and B - UHCprovider.com
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Botulinum Toxins A and B - UHCprovider.com
Botulinum Toxins A and B Page 1 of 24 UnitedHealthcare Commercial Medical Benefit Drug Policy Effective 04/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. UnitedHealthcare Commercial Medica l Benefit Drug Policy Botulinum Toxins A and B Policy Number: 2021D0017AB Effective Date: April 1, 2021 Instructions for Use Table of Contents Page Coverage Rationale .. 1 Applicable Codes .. 6 8 Benefit Considerations .. 8 Clinical Evidence .. 8 Food and Drug Administration .. 18 References .. 19 Policy History/Revision Information .. 23 Instructions for Use .. 23 Coverage Rationale See Benefit Considerations This policy refers to the following Botulinum toxin types A and B: Dysport (abobotulinumtoxinA) Xeomin (incobotulinumtoxinA) Botox (onabotulinumtoxinA) Myobloc (rimabotulinumtoxinB) The following information pertains to medical necessity review: General Requirements (applicable to all medical necessity requests) For initial therapy, both of the following: o Diagnosis; and o Medical records documenting both of the following: History and physical examination documenting the severity of the condition; and Laboratory results or diagnostic evidence supporting the indication for which Botulinum toxin is requested and o Botulinum toxin administration is no more frequent than every 12 weeks, regardless of diagnosis.
Hemifacial spasm (seventh cranial nerve disorders) 19,80. Hyperhidrosis. 1,80. including gustatory sweating (Frey's Syndrome) 9,15,38. 1,71,80Migraine headache, chronic defined by all of the following: o Greater than or equal to 15 headache days per month o Greater than or equal to 8 migraine days per month o Headaches last 4 hours per day or ...
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