Member is diagnosed with belpharospasm including blepharospasm associated with dystonia, benign essential belpharospasm or VII nerve disorder.Member is 12 years of age or older and.Treatment of blepharospasm when all of the following are met: Treatment of chronic anal fissures when the member has not responded to first line therapy such as topical calcium channel blockers or topical nitrates Treatment of achalasia when the member has tried and failed or is a poor candidate for conventional therapy such as pneumatic dilation and surgical myotomy 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. Primary axillary, palmar, and gustatory (Frey’s syndrome) hyperhidrosis (Botox and Dysport only).Excessive salivation (chronic sialorrhea/ptyalism).Therefore, Aetna considers Myobloc (rimabotulinumtoxinB) to be medically necessary only for members who have a contraindication, intolerance or ineffective response to the available equivalent alternative botulinum toxin agents: Botox (onabotulinumtoxinA), Dysport (abobotulinumtoxinA), and Xeomin (incobotulinumtoxinA) for the following medically necessary indications: There is a lack of reliable evidence that Myobloc (rimabotulinumtoxinB) is superior to the lower cost botulinum toxin agents: Botox (onabotulinumtoxinA), Dysport (abobotulinumtoxinA), and Xeomin (incobotulinumtoxinA) for the medically necessary indications listed below. Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background Referencesīrand Selection for Medically Necessary IndicationsĪs defined in Aetna commercial policies, health care services are not medically necessary when they are more costly than alternative services that are at least as likely to produce equivalent therapeutic or diagnostic results. Myobloc (rimabotulinumtoxinB) brand is more costly to Aetna than other botulinum toxin agents for certain indications.
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