Policy

Network Health covers Botox (onabotulinum toxin A), Dysport (abobotulinum toxin A), and Myobloc (rimabotulinum toxin B) products with prior authorization for Network Health Together^®, Network Health Forward^®, Network Health Extend^™, and Network Health Choice members who meet specific coverage criteria. Botox, Dysport, and Myobloc are available as a pharmacy benefit through our specialty pharmacy program or as a medical benefit.

Covered conditions

Network Health covers Botox for the following conditions:  

• Strabismus associated with dystonia in members 12 years and older
• Blepharospasms associated with dystonia in members 12 years and older
• Seventh cranial nerve disorders such as hemifacial spasm, jaw closing oromandibular dystonia, masseter spasticity, and orofacial dyskinesia in members 12 years and older
• Primary axillary hyperhidrosis inadequately treated with topical agents (e.g., Drysol, aluminum chloride hexahydrate 20%)
• Spasmodic torticollis or cervical dystonia in members 16 years and older
• Upper/lower limb spasticity due to cerebral palsy in pediatric members
• Upper/lower limb spasticity due to multiple sclerosis, stroke, brain injury, or spinal cord injury
• Achalasia in members who failed pneumatic dilation or surgical myotomy or have a high risk of complications from these treatments
• Spasmodic dysphonia, laryngeal dysphonia (laryngeal spasm), or laryngeal dystonia
• Urinary incontinence in members who failed pharmacotherapy (e.g., oxybutynin, tolterodine, fesoterodine, darifenacin, solifenacin, trospium) due to detrusor overactivity (detrusor hyperreflexia) caused by a spinal cord injury
• Chronic anal fissures in members who are refractory to conservative therapy (e.g., nitroglycerin anal ointment)
• Chronic migraine headaches when the member meets all of the following criteria:
• Has been evaluated by a neurologist or headache specialist
• Has tried and failed treatment with two other forms of prophylactic therapy (e.g. beta blockers, calcium channel blockers, antidepressants, anti-epileptics)
• Has been compliant with prior therapy for chronic migraines

Network Health covers Dysport for the following condition:

• Spasmodic torticollis or cervical dystonia in members 18 years of age or older

Network Health covers Myobloc for the following condition:

• Spasmodic torticollis or cervical dystonia in members 16 years of age or older

Please note: Network Health will approve one year of initial treatment with Botox, Dysport or Myobloc if a member meets all of the initial criteria for a condition described earlier. Network Health will continue to approve Botox, Dysport or Myobloc treatment on an annual basis for the covered conditions described earlier when a provider provides clinical documentation (e.g., office note, specialist note) of member improvement while receiving Botox, Dysport or Myobloc.

Noncovered conditions

Network Health does not cover Botox or Myobloc for the following conditions:

• Cosmetic uses including, but not limited to, glabellar lines (wrinkles and frown lines), aging neck, and blepharoplasty (eyelid lift)
• Headaches including, but not limited to, cervicogenic, cluster, or tension-type. Network Health considers the use of these products to treat these types of headaches as experimental and/or investigational.

Definitions

Achalasia — a rare disorder in which the muscle at the end of the esophagus does not relax enough for the passage to open properly.

Anal fissure — an unnatural crack or tear in the skin of the anal canal.

Blepharospasm — a condition in which there is sustained, forced, and involuntary closing of the eyelids.

Botulinum toxin — a medication and a neurotoxic protein produced by the bacterium Clostridium botulinum. 

Cervical dystonia (spasmodic torticollis) — a chronic neurological movement disorder causing the neck to involuntarily turn to the left and/or right, and upward and/or downward.

Chronic daily migraine — a migraine headache that occurs greater than 15 days per month and lasts longer than four hours.

Dyskinesia — the effects of diminished voluntary movements and presence of involuntary movements. 

Primary axillary hyperhidrosis — a condition characterized by excessive underarm sweating thought to result from localized hyperstimulation of sweat glands by cholinergic sympathetic nerve fibers.

Spasmodic dysphonia (laryngeal dystonia) — a voice disorder characterized by involuntary movements of one or more muscles of the larynx (vocal folds or voice box) during speech.

Spasticity — a condition in which certain muscles continuously contract causing involuntary muscle movement.

Strabismus — a condition in which the visual axes of the eyes are not parallel and the eyes appear to look in different directions.

Urinary incontinence — a condition in which urine leaks involuntarily from the bladder. 

Guidelines references

Albanese, A., Bentivoglio, A. R., Brisinda, G., Cassetta, E., Gui, D., & Maria, G. (1999, July 8). A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. New England Journal of Medicine. 341 (2), 65-69.

Argoff, C. E., Childers, M. K., Dykstra, D. D., Gronseth, G. S., Jabbari, B.,  Kaufmann, H. C., Naumann, M., Schurch, B., Silberstein, S. D., Simpson, D. M., & So, Y. (2008). Assessment: Botulinum neurotoxin in the treatment of autonomic disorders and pain (an evidence-based review): Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 70, 1707-1714.

Aurora, S.K., Brin, M.F., DeGryse, R.E., Diener, H.C., Dodick, D.W., Lipton, R.B., Silberstein, S.D., Turkel, C.C. (2010). OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo controlled phase of the PREEMPT 1 trial. Cephalagia. 30:793.

Aurora, S.K., Brin, M.F., DeGryse, R.E., Diener, H.C., Dodick, D.W., Lipton, R.B., Silberstein, S.D., Turkel, C.C. (2010). OnabotulinumtoxinA for treatment of chronic migraine; results from the double-blind, randomized, placebo controlled phase of the PREEMPT 2 trial. Cephalagia. 30:804.

Blitzer, A., Brashear, A., Comella, C., Dubinsky, R., Hallett, M., Jankovic, J., Karp, B., Ludlow, C. L., Miyasaki, J. M., Naumann, M., Simpson, D. M., & So, Y. (2008). Assessment: Botulinum neurotoxin for the treatment of movement disorders (an evidence-based review): Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 70, 1699-1706.

Botox. Allergan Pharmaceuticals. (Package Insert)

Botulinum Toxin Treatment for Gastrointestinal Disorders. (2003, December). (Hayes accessed March 2009).

Botulinum Toxin Treatment for Hyperhidrosis. (2008, January). (Hayes accessed March 2009).

Botulinum Toxin Treatment for Spasticity Following Stroke. (2008, December). (Hayes accessed March 2009).

Botulinum Toxin Treatment for Spasticity Due to Cerebral Palsy. (2008, November). (Hayes accessed March 2009).

Dasgupta, P., Khan, M. S., & Sahai, A. (2007). Efficacy of botulinum toxin-A for treating idiopathic detrusor overactivity: results from a single center, randomized, double-blind, placebo controlled trial. The Journal of Urology. 177, 2231.

Fachnie, B., Kolbasnik, J., Tougas, G., Waterfall, W. E., & Ying, C. (1999). Long-term efficacy of Botulinum toxin in classical achalasia: A prospective study. The American Journal of Gastroenterology. 94, 3434-3439.

Fishman, V. M., Parkman, H. P., Schiano, T. D., & et al. (1996). Symptomatic improvement in achalasia after botulinum toxin injection of the lower esophageal sphincter. The American Journal of Gastroenterology. 91, 1724.

Fowler, C. J., Ghei, M., Malone-Lee, J., Maraj, B. H., Miller, R., Nathan, S., O’Sullivan, C., & Shan, P. J. R. (2005). Effects of botulinum toxin B on refractory detrusor overactivity: a randomized, double-blind, placebo controlled, crossover trial. The Journal of Urology. 174, 1873-1877.

Gracies, J. M., Graham, H. K., Miyasaki, J. M., Naumann, M., Russman, B., Simpson, D. M., Simpson, L. L., & So, Y. (2008). Assessment: Botulinum neurotoxin for the treatment of spasticity (an evidence-based review): Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 70, 1691-1698. 

These guidelines apply to Network Health Together, Network Health Forward, Network Health Extend, and Network Health Choice plans. Coverage is based on member benefits and eligibility; medical necessity review, where applicable; and the Network Health provider agreement. Adherence to these guidelines by a provider does not guarantee coverage. Network Health reserves the right to amend these guidelines at its discretion. 04181