![]() First bite syndrome: neurologist or oncologist.Īetna considers onabotulinumtoxinA (Botox) medically necessary for any of the following indications:.Excessive salivation, spasmodic dystonia, oromandibular dystonia, bruxism, palatal myoclonus: neurologist or otolaryngologist.Chronic anal fissures, achalasia, Hirschsprung disease: gastroenterologist, proctologist or colorectal surgeon.Migraine prophylaxis, tremor, orofacial tardive dyskinesia: neurologist.Hyperhidrosis: neurologist or dermatologist.Spasticity, cervical dystonia, hemifacial spasm, myofascial pain syndrome, focal hand dystonia, facial myokymia: neurologist, orthopedist, or physiatrist.Overactive bladder, urinary incontinence: neurologist or urologist.Blepharospasm, strabismus: neurologist or ophthalmologist.The medication must be prescribed by, or in consultation with, one of the following: OnabotulinumtoxinA (Botox Brand of Botulinum Toxin Type A).For precertification of botulinum toxin (Botox Dysport Myobloc and Xeomin ), call (866) 752-7021 (commercial), or fax (888) 267-3277. Precertification of botulinum toxin (Botox Dysport Myobloc and Xeomin ) is required of all Aetna participating providers and members in applicable plan designs. Dysport is contraindicated for the member.Inadequate response to a trial of Dysport.Xeomin is contraindicated for the member.Inadequate response to a trial of Xeomin.Dysport or Xeomin is contraindicated for the member.Intolerable adverse event to Dysport or Xeomin.Inadequate response to a trial of Dysport or Xeomin.Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background Referencesīotox and Myobloc, for the indications listed below:Īre not covered for new starts, unless the member meets ANY of the following:
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