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 diagnosti
Myofascial pain syndrome 45,72,81 Nasal hypersecretion 50,67 Pain and/or wound healing after hemorrhoidectomy Pancreas divisum Pelvic floor spasticity (and associated pain conditions) Piriformis syndrome Post-parotidectomy sialoceles Post-thoracotomy pseudoangina 18,Proctalgia fugax 41Severe bruxism -42 Severe paradoxical vocal cord movement
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