Aetna Botulinum Toxin coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• GENERAL (all formulations): Must be prescribed by or in consultation with a provider specialized in treating the member's condition; cosmetic use is ineligible.
• Botox (onabotulinumtoxinA) - Achalasia: when the member has tried and failed or is a poor candidate for conventional therapy such as pneumatic dilation and surgical myotomy.
• Botox (onabotulinumtoxinA) - Chronic anal fissures: when the member has not responded to first-line therapy such as topical calcium channel blockers or topical nitrates.
• Botox (onabotulinumtoxinA) - Blepharospasm (meet ALL): member age >=12 years; AND diagnosed with blepharospasm including blepharospasm associated with dystonia, benign essential blepharospasm, or VII nerve disorder.
• Botox (onabotulinumtoxinA) - Cervical dystonia (meet ALL): abnormal placement of the head with limited range of motion in the neck; AND member age >=18 years.
• Botox (onabotulinumtoxinA) - Chronic sialorrhea (excessive salivation): when the member has been refractory to pharmacotherapy (e.g., anticholinergics).
• Botox (onabotulinumtoxinA) - Essential tremor: treatment of essential tremor.
• Botox (onabotulinumtoxinA) - Facial myokymia: treatment of facial myokymia.
• Botox (onabotulinumtoxinA) - First bite syndrome: when the member has failed relief from analgesics, antidepressants, or anticonvulsants.
• Botox (onabotulinumtoxinA) - Focal hand dystonia: treatment of focal hand dystonias.
• Botox (onabotulinumtoxinA) - Hemifacial spasm: treatment of hemifacial spasm.
• Botox (onabotulinumtoxinA) - Hirschsprung disease with internal sphincter achalasia: following endorectal pull-through and the member is refractory to laxative therapy.
• Botox (onabotulinumtoxinA) - Chronic migraine prophylaxis (meet ALL): member experiences headaches 15 days or more per month; AND headaches lasting 4 hours or longer on at least 8 days per month; AND member completed an adequate trial of (or has a contraindication to) two migraine preventative therapies from at least 2 of the following classes, each trialed at least 60 days: antidepressants (amitriptyline, venlafaxine), antiepileptic drugs (divalproex sodium, topiramate, valproate sodium), beta-adrenergic blocking agents (metoprolol, propranolol, timolol, atenolol, nadolol), CGRP-targeting therapies (fremanezumab, galcanezumab, eptinezumab, rimegepant, atogepant); AND signs and symptoms consistent with chronic migraine diagnostic criteria as defined by the International Headache Society (IHS); AND member age >=18 years.
• Botox (onabotulinumtoxinA) - Myofascial pain syndrome (tried and failed ALL): physical therapy; AND injection of local anesthetics into trigger points; AND injection of corticosteroids into trigger points.
• Botox (onabotulinumtoxinA) - Orofacial tardive dyskinesia: when conventional therapies have been tried and failed (e.g., benzodiazepines, clozapine, or tetrabenazine).
• Botox (onabotulinumtoxinA) - Oromandibular dystonia: treatment of oromandibular dystonia.
• Botox (onabotulinumtoxinA) - Overactive bladder with urinary incontinence (meet ALL): member has tried and failed behavioral therapy; AND had an inadequate response or intolerance to two agents from either of the following classes - anticholinergic medication (Vesicare, Enablex, Toviaz, Detrol/Detrol LA, Sanctura/Sanctura XR, Ditropan XL) OR beta-3 adrenergic agonist (Myrbetriq, Gemtesa); AND member age >=18 years.
• Botox (onabotulinumtoxinA) - Painful bruxism: when the member has had an inadequate response to a night guard AND an inadequate response to pharmacologic therapy such as diazepam.
• Botox (onabotulinumtoxinA) - Palatal myoclonus: when the member has disabling symptoms (e.g., intrusive clicking tinnitus) and had an inadequate response to clonazepam, lamotrigine, carbamazepine, or valproate.
• Botox (onabotulinumtoxinA) - Primary axillary, palmar, and gustatory (Frey's syndrome) hyperhidrosis (meet ALL): significant disruption of professional and/or social life has occurred because of excessive sweating; AND topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash; AND member age >=18 years.
• Botox (onabotulinumtoxinA) - Spasmodic dysphonia (laryngeal dystonia): treatment of spasmodic dysphonia (laryngeal dystonia).
• Botox (onabotulinumtoxinA) - Strabismus (meet ALL): strabismus interference with normal visual system development is likely to occur and spontaneous recovery is unlikely; AND member age >=12 years. NOTE: strabismus repair is considered cosmetic in adults with uncorrected congenital strabismus and no binocular fusion.
• Botox (onabotulinumtoxinA) - Upper or lower limb spasticity (meet ALL): member age >=2 years; AND member has a primary diagnosis of upper or lower limb spasticity or as a symptom of a condition causing limb spasticity (including focal spasticity or equinus gait due to cerebral palsy).
• Botox (onabotulinumtoxinA) - Urinary incontinence due to detrusor overactivity associated with a neurologic condition (e.g., spinal cord injury, multiple sclerosis) (meet ALL): member has tried and failed behavioral therapy; AND had an inadequate response or intolerance to one agent from either of the following classes - anticholinergic medication OR beta-3 adrenergic agonist; AND member age >=5 years.
• Botox (onabotulinumtoxinA) - Continuation of therapy: reauthorization is medically necessary when the member meets initial criteria and is experiencing benefit from therapy (excluding chronic migraine).
• Botox (onabotulinumtoxinA) - Continuation for chronic migraine: medically necessary when the member has achieved or maintained a reduction in monthly headache frequency since starting therapy with onabotulinumtoxinA (Botox).
• Myobloc (rimabotulinumtoxinB) - BRAND-SELECTION GATE: Myobloc is more costly than other botulinum toxin agents and is medically necessary ONLY for members who have a contraindication, intolerance, or ineffective response to the available equivalent alternative botulinum toxin agents (Botox, Daxxify, Dysport, and Xeomin), for the indications below.
• Myobloc (rimabotulinumtoxinB) - Cervical dystonia (meet ALL): contraindication, intolerance, or ineffective response to ALL of Botox, Daxxify, Dysport, and Xeomin; AND member age >=18 years; AND abnormal placement of the head with limited range of motion in the neck.
• Myobloc (rimabotulinumtoxinB) - Chronic sialorrhea (excessive salivation) (meet ALL): contraindication, intolerance, or ineffective response to the available equivalent alternative botulinum toxin Xeomin; AND member age >=18 years; AND refractory to pharmacotherapy (e.g., anticholinergics).
• Myobloc (rimabotulinumtoxinB) - Primary axillary and palmar hyperhidrosis (meet ALL): significant disruption of professional and/or social life has occurred because of excessive sweating; AND topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash.
• Myobloc (rimabotulinumtoxinB) - Upper limb spasticity: either as a primary diagnosis or as a symptom of a condition causing limb spasticity.
• Myobloc (rimabotulinumtoxinB) - Continuation of therapy: reauthorization is medically necessary when the member meets all initial authorization criteria and is experiencing benefit from therapy.
• Dysport (abobotulinumtoxinA) - Blepharospasm: including blepharospasm associated with dystonia and benign essential blepharospasm.
• Dysport (abobotulinumtoxinA) - Cervical dystonia (meet ALL): member age >=18 years; AND abnormal placement of the head with limited range of motion in the neck.
• Dysport (abobotulinumtoxinA) - Chronic anal fissures: when the member has not responded to first-line therapy such as topical calcium channel blockers or topical nitrates.
• Dysport (abobotulinumtoxinA) - Chronic sialorrhea (excessive salivation): when the member has been refractory to pharmacotherapy (e.g., anticholinergics).
• Dysport (abobotulinumtoxinA) - Hemifacial spasm: treatment of hemifacial spasm.
• Dysport (abobotulinumtoxinA) - Primary axillary hyperhidrosis (meet ALL): significant disruption of professional and/or social life has occurred because of excessive sweating; AND topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash.
• Dysport (abobotulinumtoxinA) - Upper or lower limb spasticity (meet ALL): member age >=2 years; AND member has a primary diagnosis of upper or lower limb spasticity or as a symptom of a condition causing limb spasticity (e.g., focal spasticity or equinus gait due to cerebral palsy).
• Dysport (abobotulinumtoxinA) - Continuation of therapy: reauthorization is medically necessary when the member meets initial criteria and is experiencing benefit from therapy.
• Xeomin (incobotulinumtoxinA) - Blepharospasm (meet ALL): member has a diagnosis of blepharospasm including benign essential blepharospasm or blepharospasm associated with dystonia; AND member age >=18 years.
• Xeomin (incobotulinumtoxinA) - Cervical dystonia (meet ALL): member age >=18 years; AND abnormal placement of the head with limited range of motion in the neck.
• Xeomin (incobotulinumtoxinA) - Chronic sialorrhea (excessive salivation) (meet ALL): member age >=2 years; AND refractory to pharmacotherapy (e.g., anticholinergics).
• Xeomin (incobotulinumtoxinA) - Upper limb spasticity (meet ALL): member has a diagnosis of upper limb spasticity either as a primary diagnosis or as a symptom of a condition causing limb spasticity; AND meet ONE of: member age >=18 years OR member is 2 to 17 years of age and the spasticity is not caused by cerebral palsy.
• Xeomin (incobotulinumtoxinA) - Continuation of therapy: reauthorization is medically necessary when the member meets initial criteria and is experiencing benefit from therapy.
• Daxxify (daxibotulinumtoxinA-lanm) - Cervical dystonia in adults (meet ALL; ONLY covered indication): member age >=18 years; AND abnormal placement of the head with limited range of motion in the neck.
• Daxxify (daxibotulinumtoxinA-lanm) - Continuation of therapy: reauthorization is medically necessary when the member meets initial criteria and is experiencing benefit from therapy.
• EMG guidance for botulinum toxin injections - medically necessary for ONE of: cervical dystonia, hand dystonia, laryngeal dystonia / spasmodic dysphonia, limb spasticity, or strabismus.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 64611·PA verdict·Rate
• 64612·PA verdict·Rate
• 64615·PA verdict·Rate
• 64616·PA verdict·Rate
• 64617·PA verdict·Rate
• 64642·PA verdict·Rate
• 64643·PA verdict·Rate
• 64644·PA verdict·Rate
• 64645·PA verdict·Rate
• 64646·PA verdict·Rate
• 64647·PA verdict·Rate
• 64650·PA verdict·Rate
• 64653·PA verdict·Rate
• 67345·PA verdict·Rate

Documentation required

• Statement of Medical Necessity (SMN) precertification forms must be completed and submitted (available via Specialty Pharmacy Precertification).
• Documentation supporting the applicable initial-approval clinical criteria for the requested formulation and indication (e.g., diagnosis, age, prior trial-and-failure of required therapies, IHS chronic migraine criteria).
• For continuation/reauthorization, documentation that the member continues to meet initial criteria and is experiencing benefit from therapy (for chronic migraine, documentation of an achieved/maintained reduction in monthly headache frequency).
• Approvals may be subject to dosing/quantity limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines (reference the Medical Specialty Medication Quantity Limits document).

Frequently asked questions

When does Aetna cover Botulinum Toxin (CPT 64611), and what gets it denied?

Aetna CPB 0113 covers botulinum toxin products (Botox, Dysport, Xeomin, Myobloc, Daxxify) only for specific medically necessary neuromuscular, dystonic, spasticity, bladder, hyperhidrosis, sialorrhea, and chronic-migraine indications, each with its own age limits and prior-therapy/trial-and-failure gates, and only when prescribed by or in consultation with a specialist. Cosmetic use is never covered, Myobloc is restricted to members who fail or cannot tolerate the other agents, and a long list of other indications is deemed experimental/investigational. Precertification is explicitly required for all listed formulations. Coverage criteria include: GENERAL (all formulations): Must be prescribed by or in consultation with a provider specialized in treating the member's condition; cosmetic use is ineligible.; Botox (onabotulinumtoxinA) - Achalasia: when the member has tried and failed or is a poor candidate for conventional therapy such as pneumatic dilation and surgical myotomy.; Botox (onabotulinumtoxinA) - Chronic anal fissures: when the member has not responded to first-line therapy such as topical calcium channel blockers or topical nitrates.; Botox (onabotulinumtoxinA) - Blepharospasm (meet ALL): member age >=12 years; AND diagnosed with blepharospasm including blepharospasm associated with dystonia, benign essential blepharospasm, or VII nerve disorder.; Botox (onabotulinumtoxinA) - Cervical dystonia (meet ALL): abnormal placement of the head with limited range of motion in the neck; AND member age >=18 years.; Botox (onabotulinumtoxinA) - Chronic sialorrhea (excessive salivation): when the member has been refractory to pharmacotherapy (e.g., anticholinergics).; Botox (onabotulinumtoxinA) - Essential tremor: treatment of essential tremor.; Botox (onabotulinumtoxinA) - Facial myokymia: treatment of facial myokymia.; Botox (onabotulinumtoxinA) - First bite syndrome: when the member has failed relief from analgesics, antidepressants, or anticonvulsants.; Botox (onabotulinumtoxinA) - Focal hand dystonia: treatment of focal hand dystonias.; Botox (onabotulinumtoxinA) - Hemifacial spasm: treatment of hemifacial spasm.; Botox (onabotulinumtoxinA) - Hirschsprung disease with internal sphincter achalasia: following endorectal pull-through and the member is refractory to laxative therapy.; Botox (onabotulinumtoxinA) - Chronic migraine prophylaxis (meet ALL): member experiences headaches 15 days or more per month; AND headaches lasting 4 hours or longer on at least 8 days per month; AND member completed an adequate trial of (or has a contraindication to) two migraine preventative therapies from at least 2 of the following classes, each trialed at least 60 days: antidepressants (amitriptyline, venlafaxine), antiepileptic drugs (divalproex sodium, topiramate, valproate sodium), beta-adrenergic blocking agents (metoprolol, propranolol, timolol, atenolol, nadolol), CGRP-targeting therapies (fremanezumab, galcanezumab, eptinezumab, rimegepant, atogepant); AND signs and symptoms consistent with chronic migraine diagnostic criteria as defined by the International Headache Society (IHS); AND member age >=18 years.; Botox (onabotulinumtoxinA) - Myofascial pain syndrome (tried and failed ALL): physical therapy; AND injection of local anesthetics into trigger points; AND injection of corticosteroids into trigger points.; Botox (onabotulinumtoxinA) - Orofacial tardive dyskinesia: when conventional therapies have been tried and failed (e.g., benzodiazepines, clozapine, or tetrabenazine).; Botox (onabotulinumtoxinA) - Oromandibular dystonia: treatment of oromandibular dystonia.; Botox (onabotulinumtoxinA) - Overactive bladder with urinary incontinence (meet ALL): member has tried and failed behavioral therapy; AND had an inadequate response or intolerance to two agents from either of the following classes - anticholinergic medication (Vesicare, Enablex, Toviaz, Detrol/Detrol LA, Sanctura/Sanctura XR, Ditropan XL) OR beta-3 adrenergic agonist (Myrbetriq, Gemtesa); AND member age >=18 years.; Botox (onabotulinumtoxinA) - Painful bruxism: when the member has had an inadequate response to a night guard AND an inadequate response to pharmacologic therapy such as diazepam.; Botox (onabotulinumtoxinA) - Palatal myoclonus: when the member has disabling symptoms (e.g., intrusive clicking tinnitus) and had an inadequate response to clonazepam, lamotrigine, carbamazepine, or valproate.; Botox (onabotulinumtoxinA) - Primary axillary, palmar, and gustatory (Frey's syndrome) hyperhidrosis (meet ALL): significant disruption of professional and/or social life has occurred because of excessive sweating; AND topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash; AND member age >=18 years.; Botox (onabotulinumtoxinA) - Spasmodic dysphonia (laryngeal dystonia): treatment of spasmodic dysphonia (laryngeal dystonia).; Botox (onabotulinumtoxinA) - Strabismus (meet ALL): strabismus interference with normal visual system development is likely to occur and spontaneous recovery is unlikely; AND member age >=12 years. NOTE: strabismus repair is considered cosmetic in adults with uncorrected congenital strabismus and no binocular fusion.; Botox (onabotulinumtoxinA) - Upper or lower limb spasticity (meet ALL): member age >=2 years; AND member has a primary diagnosis of upper or lower limb spasticity or as a symptom of a condition causing limb spasticity (including focal spasticity or equinus gait due to cerebral palsy).; Botox (onabotulinumtoxinA) - Urinary incontinence due to detrusor overactivity associated with a neurologic condition (e.g., spinal cord injury, multiple sclerosis) (meet ALL): member has tried and failed behavioral therapy; AND had an inadequate response or intolerance to one agent from either of the following classes - anticholinergic medication OR beta-3 adrenergic agonist; AND member age >=5 years.; Botox (onabotulinumtoxinA) - Continuation of therapy: reauthorization is medically necessary when the member meets initial criteria and is experiencing benefit from therapy (excluding chronic migraine).; Botox (onabotulinumtoxinA) - Continuation for chronic migraine: medically necessary when the member has achieved or maintained a reduction in monthly headache frequency since starting therapy with onabotulinumtoxinA (Botox).; Myobloc (rimabotulinumtoxinB) - BRAND-SELECTION GATE: Myobloc is more costly than other botulinum toxin agents and is medically necessary ONLY for members who have a contraindication, intolerance, or ineffective response to the available equivalent alternative botulinum toxin agents (Botox, Daxxify, Dysport, and Xeomin), for the indications below.; Myobloc (rimabotulinumtoxinB) - Cervical dystonia (meet ALL): contraindication, intolerance, or ineffective response to ALL of Botox, Daxxify, Dysport, and Xeomin; AND member age >=18 years; AND abnormal placement of the head with limited range of motion in the neck.; Myobloc (rimabotulinumtoxinB) - Chronic sialorrhea (excessive salivation) (meet ALL): contraindication, intolerance, or ineffective response to the available equivalent alternative botulinum toxin Xeomin; AND member age >=18 years; AND refractory to pharmacotherapy (e.g., anticholinergics).; Myobloc (rimabotulinumtoxinB) - Primary axillary and palmar hyperhidrosis (meet ALL): significant disruption of professional and/or social life has occurred because of excessive sweating; AND topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash.; Myobloc (rimabotulinumtoxinB) - Upper limb spasticity: either as a primary diagnosis or as a symptom of a condition causing limb spasticity.; Myobloc (rimabotulinumtoxinB) - Continuation of therapy: reauthorization is medically necessary when the member meets all initial authorization criteria and is experiencing benefit from therapy.; Dysport (abobotulinumtoxinA) - Blepharospasm: including blepharospasm associated with dystonia and benign essential blepharospasm.; Dysport (abobotulinumtoxinA) - Cervical dystonia (meet ALL): member age >=18 years; AND abnormal placement of the head with limited range of motion in the neck.; Dysport (abobotulinumtoxinA) - Chronic anal fissures: when the member has not responded to first-line therapy such as topical calcium channel blockers or topical nitrates.; Dysport (abobotulinumtoxinA) - Chronic sialorrhea (excessive salivation): when the member has been refractory to pharmacotherapy (e.g., anticholinergics).; Dysport (abobotulinumtoxinA) - Hemifacial spasm: treatment of hemifacial spasm.; Dysport (abobotulinumtoxinA) - Primary axillary hyperhidrosis (meet ALL): significant disruption of professional and/or social life has occurred because of excessive sweating; AND topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash.; Dysport (abobotulinumtoxinA) - Upper or lower limb spasticity (meet ALL): member age >=2 years; AND member has a primary diagnosis of upper or lower limb spasticity or as a symptom of a condition causing limb spasticity (e.g., focal spasticity or equinus gait due to cerebral palsy).; Dysport (abobotulinumtoxinA) - Continuation of therapy: reauthorization is medically necessary when the member meets initial criteria and is experiencing benefit from therapy.; Xeomin (incobotulinumtoxinA) - Blepharospasm (meet ALL): member has a diagnosis of blepharospasm including benign essential blepharospasm or blepharospasm associated with dystonia; AND member age >=18 years.; Xeomin (incobotulinumtoxinA) - Cervical dystonia (meet ALL): member age >=18 years; AND abnormal placement of the head with limited range of motion in the neck.; Xeomin (incobotulinumtoxinA) - Chronic sialorrhea (excessive salivation) (meet ALL): member age >=2 years; AND refractory to pharmacotherapy (e.g., anticholinergics).; Xeomin (incobotulinumtoxinA) - Upper limb spasticity (meet ALL): member has a diagnosis of upper limb spasticity either as a primary diagnosis or as a symptom of a condition causing limb spasticity; AND meet ONE of: member age >=18 years OR member is 2 to 17 years of age and the spasticity is not caused by cerebral palsy.; Xeomin (incobotulinumtoxinA) - Continuation of therapy: reauthorization is medically necessary when the member meets initial criteria and is experiencing benefit from therapy.; Daxxify (daxibotulinumtoxinA-lanm) - Cervical dystonia in adults (meet ALL; ONLY covered indication): member age >=18 years; AND abnormal placement of the head with limited range of motion in the neck.; Daxxify (daxibotulinumtoxinA-lanm) - Continuation of therapy: reauthorization is medically necessary when the member meets initial criteria and is experiencing benefit from therapy.; EMG guidance for botulinum toxin injections - medically necessary for ONE of: cervical dystonia, hand dystonia, laryngeal dystonia / spasmodic dysphonia, limb spasticity, or strabismus.. Applies to 14 codes: 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, 67345. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: Statement of Medical Necessity (SMN) precertification forms must be completed and submitted (available via Specialty Pharmacy Precertification).; Documentation supporting the applicable initial-approval clinical criteria for the requested formulation and indication (e.g., diagnosis, age, prior trial-and-failure of required therapies, IHS chronic migraine criteria).; For continuation/reauthorization, documentation that the member continues to meet initial criteria and is experiencing benefit from therapy (for chronic migraine, documentation of an achieved/maintained reduction in monthly headache frequency).; Approvals may be subject to dosing/quantity limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines (reference the Medical Specialty Medication Quantity Limits document). Policy exclusions and limitations: For each formulation (Botox, Myobloc, Dysport, Xeomin, Daxxify), Aetna considers all other indications not listed as medically necessary to be experimental, investigational, or unproven.; Cosmetic use of all botulinum toxin formulations is ineligible/not covered.; Testing for neutralizing antibodies to botulinum toxin is experimental, investigational, or unproven.; EMG guidance is experimental/investigational for: treatment of bladder dysfunction.; EMG guidance is experimental/investigational for: treatment of blepharospasm.; EMG guidance is experimental/investigational for: treatment of hyperhidrosis.; EMG guidance is experimental/investigational for: treatment of migraines.; Experimental/investigational/unproven: electrical stimulation to augment effects of botulinum toxin injection for spasticity treatment.; Experimental/investigational/unproven: intra-operative pyloric botulinum toxin injection during gastroesophagectomy for prevention of delayed gastric emptying.; Experimental/investigational/unproven: ultrasound guidance during botulinum toxin injection for migraine treatment.; Experimental/investigational/unproven indication: airway obstruction in persons with bilateral vocal fold motor impairment.; Experimental/investigational/unproven indication: anal sphincter dysfunction.; Experimental/investigational/unproven indication: androgenetic alopecia.; Experimental/investigational/unproven indication: anismus (pelvic floor dyssynergia).; Experimental/investigational/unproven indication: aspiration pneumonia in neurologically impaired children.; Experimental/investigational/unproven indication: atrial fibrillation.; Experimental/investigational/unproven indication: Bell's palsy (excludes blepharospasm associated with VII nerve disorder).; Experimental/investigational/unproven indication: benign prostatic hypertrophy.; Experimental/investigational/unproven indication: biliary dyskinesia.; Experimental/investigational/unproven indication: bladder exstrophy.; Experimental/investigational/unproven indication: bladder pain syndrome.; Experimental/investigational/unproven indication: brachial plexus injury (Erb's palsy, brachial palsy in newborns).; Experimental/investigational/unproven indication: carpal tunnel syndrome.; Experimental/investigational/unproven indication: cervicalgia.; Experimental/investigational/unproven indication: cervical myelopathy.; Experimental/investigational/unproven indication: chronic constipation.; Experimental/investigational/unproven indication: chronic exertional compartment syndrome.; Experimental/investigational/unproven indication: chronic low back pain or discogenic pain.; Experimental/investigational/unproven indication: chronic neck pain (excludes medically necessary cervical dystonia).; Experimental/investigational/unproven indication: chronic parotid sialadenitis.; Experimental/investigational/unproven indication: chronic pelvic pain.; Experimental/investigational/unproven indication: chronic quadratus lumborum strain.; Experimental/investigational/unproven indication: chronic thoracic pain and spasticity.; Experimental/investigational/unproven indication: clenched fist syndrome.; Experimental/investigational/unproven indication: clubfoot.; Experimental/investigational/unproven indication: complex regional pain syndrome.; Experimental/investigational/unproven indication: congenital hypertonia.; Experimental/investigational/unproven indication: contracture of hip secondary to Legg-Perthe-Calves disease.; Experimental/investigational/unproven indication: cranial/facial pain of unknown etiology.; Experimental/investigational/unproven indication: cricopharyngeal/oropharyngeal dysphagia (excludes achalasia).; Experimental/investigational/unproven indication: depression.; Experimental/investigational/unproven indication: Duane syndrome with lateral muscle weakness.; Experimental/investigational/unproven indication: dyspareunia.; Experimental/investigational/unproven indication: dysphagia (except due to achalasia).; Experimental/investigational/unproven indication: endometriosis.; Experimental/investigational/unproven indication: episodic (non-chronic) migraine.; Experimental/investigational/unproven indication: esophageal stricture.; Experimental/investigational/unproven indication: eustachian tube dysfunction.; Experimental/investigational/unproven indication: excessive gingival display (gummy smile).; Experimental/investigational/unproven indication: fasciitis.; Experimental/investigational/unproven indication: fecal incontinence.; Experimental/investigational/unproven indication: fibromyalgia.; Experimental/investigational/unproven indication: fibromyositis.; Experimental/investigational/unproven indication: focal lower limb dystonia.; Experimental/investigational/unproven indication: forced eyelid closure syndrome.; Experimental/investigational/unproven indication: gastroparesis.; Experimental/investigational/unproven indication: Graves ophthalmopathy.; Experimental/investigational/unproven indication: head and voice tremor (excludes essential tremor).; Experimental/investigational/unproven indication: headache (cervicogenic, cluster, tension-type, chronic daily, post-traumatic, episodic migraine, hemicrania continua) - excludes chronic migraine prophylaxis.; Experimental/investigational/unproven indication: hidradenitis suppurativa.; Experimental/investigational/unproven indication: hyperhidrosis of the face/neck.; Experimental/investigational/unproven indication: hyperactive and hypertrophic frontalis muscles from chronic compensatory brow elevation.; Experimental/investigational/unproven indication: hyper-lacrimation.; Experimental/investigational/unproven indication: hypertrophic scars.; Experimental/investigational/unproven indication: injection of the pylorus during esophago-gastrectomy.; Experimental/investigational/unproven indication: interstitial cystitis.; Experimental/investigational/unproven indication: irritable colon.; Experimental/investigational/unproven indication: intra-operative relaxation of the anal sphincter during hemorrhoidectomy.; Experimental/investigational/unproven indication: keratoconjunctivitis.; Experimental/investigational/unproven indication: knee flexion contracture.; Experimental/investigational/unproven indication: knee osteoarthritis.; Experimental/investigational/unproven indication: knee pain.; Experimental/investigational/unproven indication: lateral epicondylitis (tennis elbow).; Experimental/investigational/unproven indication: lumbar dystonia.; Experimental/investigational/unproven indication: lumbar spasticity.; Experimental/investigational/unproven indication: lumbar torsion dystonia.; Experimental/investigational/unproven indication: masseter hypertrophy.; Experimental/investigational/unproven indication: meralgia paresthetica.; Experimental/investigational/unproven indication: Morton neuroma.; Experimental/investigational/unproven indication: motor tics.; Experimental/investigational/unproven indication: neuropathic pain (complex regional pain syndrome, diabetic neuropathy, post-herpetic neuralgia, occipital neuralgia, post-traumatic neuralgia, pudendal neuralgia, trigeminal neuralgia).; Experimental/investigational/unproven indication: notalgia paresthetica.; Experimental/investigational/unproven indication: nystagmus.; Experimental/investigational/unproven indication: obesity.; Experimental/investigational/unproven indication: obturator internus syndrome.; Experimental/investigational/unproven indication: osteo-articular joint pain.; Experimental/investigational/unproven indication: pain control in breast reconstruction with tissue expanders.; Experimental/investigational/unproven indication: painful cramps.; Experimental/investigational/unproven indication: painful scars.; Experimental/investigational/unproven indication: paradoxical vocal cord motion in asthmatics (excludes laryngeal dystonia).; Experimental/investigational/unproven indication: Parkinson's disease dystonia.; Experimental/investigational/unproven indication: parotitis.; Experimental/investigational/unproven indication: pectoralis minor syndrome.; Experimental/investigational/unproven indication: pelvic floor tension myalgia (coccygodynia, diaphragma pelvis spastica, levator ani syndrome, levator spasm syndrome, spastic pelvic floor syndrome).; Experimental/investigational/unproven indication: phantom limb pain.; Experimental/investigational/unproven indication: phonic tics (excludes laryngeal dystonia).; Experimental/investigational/unproven indication: piriformis syndrome.; Experimental/investigational/unproven indication: popliteal artery entrapment syndrome.; Experimental/investigational/unproven indication: post-hemorrhoidectomy pain.; Experimental/investigational/unproven indication: post-concussion headaches.; Experimental/investigational/unproven indication: post-parotidectomy sialocele.; Experimental/investigational/unproven indication: post-traumatic headaches.; Experimental/investigational/unproven indication: puberphonia.; Experimental/investigational/unproven indication: pylorospasm.; Experimental/investigational/unproven indication: quivering chin syndrome.; Experimental/investigational/unproven indication: Raynaud's phenomenon / Raynaud's scleroderma.; Experimental/investigational/unproven indication: reduction of mucin secretion.; Experimental/investigational/unproven indication: reduction of muscle tension after hamstring avulsion repair.; Experimental/investigational/unproven indication: restless legs syndrome.; Experimental/investigational/unproven indication: retrograde cricopharyngeal dysfunction.; Experimental/investigational/unproven indication: rosacea.; Experimental/investigational/unproven indication: scalp hyper-seborrhea.; Experimental/investigational/unproven indication: Schwalbe-Ziehen-Oppenheim disease.; Experimental/investigational/unproven indication: sciatica.; Experimental/investigational/unproven indication: scoliosis.; Experimental/investigational/unproven indication: shoulder pain.; Experimental/investigational/unproven indication: Soto's syndrome.; Experimental/investigational/unproven indication: spasm of the pectoralis muscle after breast reconstruction.; Experimental/investigational/unproven indication: sphincter of Oddi dysfunction (chronic biliary pain).; Experimental/investigational/unproven indication: spina bifida.; Experimental/investigational/unproven indication: stiff person syndrome.; Experimental/investigational/unproven indication: stuttering.; Experimental/investigational/unproven indication: temporomandibular joint disorders.; Experimental/investigational/unproven indication: tendon contracture.; Experimental/investigational/unproven indication: testicular pain (cremasteric synkinesia).; Experimental/investigational/unproven indication: thoracic outlet syndrome.; Experimental/investigational/unproven indication: tinnitus (excludes palatal myoclonus).; Experimental/investigational/unproven indication: Tourette's syndrome (includes abdominal dystonic movements).; Experimental/investigational/unproven indication: treatment of chorea.; Experimental/investigational/unproven indication: treatment of cleft lip and palate repair.; Experimental/investigational/unproven indication: treatment of complications associated with breast implants.; Experimental/investigational/unproven indication: treatment of facial scars or mastectomy scars.; Experimental/investigational/unproven indication: treatment of submandibular gland obstruction.; Experimental/investigational/unproven indication: treatment of vesicovaginal fistula.; Experimental/investigational/unproven indication: ulcers.; Experimental/investigational/unproven indication: vaginismus.; Experimental/investigational/unproven indication: ventral hernia.; Experimental/investigational/unproven indication: vocal cord paralysis.; Experimental/investigational/unproven indication: vulvodynia.; Experimental/investigational/unproven indication: whiplash-related disorders.; Cosmetic (not covered) indication: aging neck.; Cosmetic (not covered) indication: blepharoplasty (eyelid lift).; Cosmetic (not covered) indication: canthal rhytide.; Cosmetic (not covered) indication: crow's feet.; Cosmetic (not covered) indication: cutaneous scar (facial wounds).; Cosmetic (not covered) indication: deep forehead lines.; Cosmetic (not covered) indication: deep nasolabial folds.; Cosmetic (not covered) indication: glabellar lines.; Cosmetic (not covered) indication: hyperkinetic facial lines.; Cosmetic (not covered) indication: wrinkles, frown lines. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Botulinum Toxin?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: Statement of Medical Necessity (SMN) precertification forms must be completed and submitted (available via Specialty Pharmacy Precertification).; Documentation supporting the applicable initial-approval clinical criteria for the requested formulation and indication (e.g., diagnosis, age, prior trial-and-failure of required therapies, IHS chronic migraine criteria).; For continuation/reauthorization, documentation that the member continues to meet initial criteria and is experiencing benefit from therapy (for chronic migraine, documentation of an achieved/maintained reduction in monthly headache frequency).; Approvals may be subject to dosing/quantity limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines (reference the Medical Specialty Medication Quantity Limits document).

What does Aetna exclude for Botulinum Toxin?

Policy exclusions and limitations: For each formulation (Botox, Myobloc, Dysport, Xeomin, Daxxify), Aetna considers all other indications not listed as medically necessary to be experimental, investigational, or unproven.; Cosmetic use of all botulinum toxin formulations is ineligible/not covered.; Testing for neutralizing antibodies to botulinum toxin is experimental, investigational, or unproven.; EMG guidance is experimental/investigational for: treatment of bladder dysfunction.; EMG guidance is experimental/investigational for: treatment of blepharospasm.; EMG guidance is experimental/investigational for: treatment of hyperhidrosis.; EMG guidance is experimental/investigational for: treatment of migraines.; Experimental/investigational/unproven: electrical stimulation to augment effects of botulinum toxin injection for spasticity treatment.; Experimental/investigational/unproven: intra-operative pyloric botulinum toxin injection during gastroesophagectomy for prevention of delayed gastric emptying.; Experimental/investigational/unproven: ultrasound guidance during botulinum toxin injection for migraine treatment.; Experimental/investigational/unproven indication: airway obstruction in persons with bilateral vocal fold motor impairment.; Experimental/investigational/unproven indication: anal sphincter dysfunction.; Experimental/investigational/unproven indication: androgenetic alopecia.; Experimental/investigational/unproven indication: anismus (pelvic floor dyssynergia).; Experimental/investigational/unproven indication: aspiration pneumonia in neurologically impaired children.; Experimental/investigational/unproven indication: atrial fibrillation.; Experimental/investigational/unproven indication: Bell's palsy (excludes blepharospasm associated with VII nerve disorder).; Experimental/investigational/unproven indication: benign prostatic hypertrophy.; Experimental/investigational/unproven indication: biliary dyskinesia.; Experimental/investigational/unproven indication: bladder exstrophy.; Experimental/investigational/unproven indication: bladder pain syndrome.; Experimental/investigational/unproven indication: brachial plexus injury (Erb's palsy, brachial palsy in newborns).; Experimental/investigational/unproven indication: carpal tunnel syndrome.; Experimental/investigational/unproven indication: cervicalgia.; Experimental/investigational/unproven indication: cervical myelopathy.; Experimental/investigational/unproven indication: chronic constipation.; Experimental/investigational/unproven indication: chronic exertional compartment syndrome.; Experimental/investigational/unproven indication: chronic low back pain or discogenic pain.; Experimental/investigational/unproven indication: chronic neck pain (excludes medically necessary cervical dystonia).; Experimental/investigational/unproven indication: chronic parotid sialadenitis.; Experimental/investigational/unproven indication: chronic pelvic pain.; Experimental/investigational/unproven indication: chronic quadratus lumborum strain.; Experimental/investigational/unproven indication: chronic thoracic pain and spasticity.; Experimental/investigational/unproven indication: clenched fist syndrome.; Experimental/investigational/unproven indication: clubfoot.; Experimental/investigational/unproven indication: complex regional pain syndrome.; Experimental/investigational/unproven indication: congenital hypertonia.; Experimental/investigational/unproven indication: contracture of hip secondary to Legg-Perthe-Calves disease.; Experimental/investigational/unproven indication: cranial/facial pain of unknown etiology.; Experimental/investigational/unproven indication: cricopharyngeal/oropharyngeal dysphagia (excludes achalasia).; Experimental/investigational/unproven indication: depression.; Experimental/investigational/unproven indication: Duane syndrome with lateral muscle weakness.; Experimental/investigational/unproven indication: dyspareunia.; Experimental/investigational/unproven indication: dysphagia (except due to achalasia).; Experimental/investigational/unproven indication: endometriosis.; Experimental/investigational/unproven indication: episodic (non-chronic) migraine.; Experimental/investigational/unproven indication: esophageal stricture.; Experimental/investigational/unproven indication: eustachian tube dysfunction.; Experimental/investigational/unproven indication: excessive gingival display (gummy smile).; Experimental/investigational/unproven indication: fasciitis.; Experimental/investigational/unproven indication: fecal incontinence.; Experimental/investigational/unproven indication: fibromyalgia.; Experimental/investigational/unproven indication: fibromyositis.; Experimental/investigational/unproven indication: focal lower limb dystonia.; Experimental/investigational/unproven indication: forced eyelid closure syndrome.; Experimental/investigational/unproven indication: gastroparesis.; Experimental/investigational/unproven indication: Graves ophthalmopathy.; Experimental/investigational/unproven indication: head and voice tremor (excludes essential tremor).; Experimental/investigational/unproven indication: headache (cervicogenic, cluster, tension-type, chronic daily, post-traumatic, episodic migraine, hemicrania continua) - excludes chronic migraine prophylaxis.; Experimental/investigational/unproven indication: hidradenitis suppurativa.; Experimental/investigational/unproven indication: hyperhidrosis of the face/neck.; Experimental/investigational/unproven indication: hyperactive and hypertrophic frontalis muscles from chronic compensatory brow elevation.; Experimental/investigational/unproven indication: hyper-lacrimation.; Experimental/investigational/unproven indication: hypertrophic scars.; Experimental/investigational/unproven indication: injection of the pylorus during esophago-gastrectomy.; Experimental/investigational/unproven indication: interstitial cystitis.; Experimental/investigational/unproven indication: irritable colon.; Experimental/investigational/unproven indication: intra-operative relaxation of the anal sphincter during hemorrhoidectomy.; Experimental/investigational/unproven indication: keratoconjunctivitis.; Experimental/investigational/unproven indication: knee flexion contracture.; Experimental/investigational/unproven indication: knee osteoarthritis.; Experimental/investigational/unproven indication: knee pain.; Experimental/investigational/unproven indication: lateral epicondylitis (tennis elbow).; Experimental/investigational/unproven indication: lumbar dystonia.; Experimental/investigational/unproven indication: lumbar spasticity.; Experimental/investigational/unproven indication: lumbar torsion dystonia.; Experimental/investigational/unproven indication: masseter hypertrophy.; Experimental/investigational/unproven indication: meralgia paresthetica.; Experimental/investigational/unproven indication: Morton neuroma.; Experimental/investigational/unproven indication: motor tics.; Experimental/investigational/unproven indication: neuropathic pain (complex regional pain syndrome, diabetic neuropathy, post-herpetic neuralgia, occipital neuralgia, post-traumatic neuralgia, pudendal neuralgia, trigeminal neuralgia).; Experimental/investigational/unproven indication: notalgia paresthetica.; Experimental/investigational/unproven indication: nystagmus.; Experimental/investigational/unproven indication: obesity.; Experimental/investigational/unproven indication: obturator internus syndrome.; Experimental/investigational/unproven indication: osteo-articular joint pain.; Experimental/investigational/unproven indication: pain control in breast reconstruction with tissue expanders.; Experimental/investigational/unproven indication: painful cramps.; Experimental/investigational/unproven indication: painful scars.; Experimental/investigational/unproven indication: paradoxical vocal cord motion in asthmatics (excludes laryngeal dystonia).; Experimental/investigational/unproven indication: Parkinson's disease dystonia.; Experimental/investigational/unproven indication: parotitis.; Experimental/investigational/unproven indication: pectoralis minor syndrome.; Experimental/investigational/unproven indication: pelvic floor tension myalgia (coccygodynia, diaphragma pelvis spastica, levator ani syndrome, levator spasm syndrome, spastic pelvic floor syndrome).; Experimental/investigational/unproven indication: phantom limb pain.; Experimental/investigational/unproven indication: phonic tics (excludes laryngeal dystonia).; Experimental/investigational/unproven indication: piriformis syndrome.; Experimental/investigational/unproven indication: popliteal artery entrapment syndrome.; Experimental/investigational/unproven indication: post-hemorrhoidectomy pain.; Experimental/investigational/unproven indication: post-concussion headaches.; Experimental/investigational/unproven indication: post-parotidectomy sialocele.; Experimental/investigational/unproven indication: post-traumatic headaches.; Experimental/investigational/unproven indication: puberphonia.; Experimental/investigational/unproven indication: pylorospasm.; Experimental/investigational/unproven indication: quivering chin syndrome.; Experimental/investigational/unproven indication: Raynaud's phenomenon / Raynaud's scleroderma.; Experimental/investigational/unproven indication: reduction of mucin secretion.; Experimental/investigational/unproven indication: reduction of muscle tension after hamstring avulsion repair.; Experimental/investigational/unproven indication: restless legs syndrome.; Experimental/investigational/unproven indication: retrograde cricopharyngeal dysfunction.; Experimental/investigational/unproven indication: rosacea.; Experimental/investigational/unproven indication: scalp hyper-seborrhea.; Experimental/investigational/unproven indication: Schwalbe-Ziehen-Oppenheim disease.; Experimental/investigational/unproven indication: sciatica.; Experimental/investigational/unproven indication: scoliosis.; Experimental/investigational/unproven indication: shoulder pain.; Experimental/investigational/unproven indication: Soto's syndrome.; Experimental/investigational/unproven indication: spasm of the pectoralis muscle after breast reconstruction.; Experimental/investigational/unproven indication: sphincter of Oddi dysfunction (chronic biliary pain).; Experimental/investigational/unproven indication: spina bifida.; Experimental/investigational/unproven indication: stiff person syndrome.; Experimental/investigational/unproven indication: stuttering.; Experimental/investigational/unproven indication: temporomandibular joint disorders.; Experimental/investigational/unproven indication: tendon contracture.; Experimental/investigational/unproven indication: testicular pain (cremasteric synkinesia).; Experimental/investigational/unproven indication: thoracic outlet syndrome.; Experimental/investigational/unproven indication: tinnitus (excludes palatal myoclonus).; Experimental/investigational/unproven indication: Tourette's syndrome (includes abdominal dystonic movements).; Experimental/investigational/unproven indication: treatment of chorea.; Experimental/investigational/unproven indication: treatment of cleft lip and palate repair.; Experimental/investigational/unproven indication: treatment of complications associated with breast implants.; Experimental/investigational/unproven indication: treatment of facial scars or mastectomy scars.; Experimental/investigational/unproven indication: treatment of submandibular gland obstruction.; Experimental/investigational/unproven indication: treatment of vesicovaginal fistula.; Experimental/investigational/unproven indication: ulcers.; Experimental/investigational/unproven indication: vaginismus.; Experimental/investigational/unproven indication: ventral hernia.; Experimental/investigational/unproven indication: vocal cord paralysis.; Experimental/investigational/unproven indication: vulvodynia.; Experimental/investigational/unproven indication: whiplash-related disorders.; Cosmetic (not covered) indication: aging neck.; Cosmetic (not covered) indication: blepharoplasty (eyelid lift).; Cosmetic (not covered) indication: canthal rhytide.; Cosmetic (not covered) indication: crow's feet.; Cosmetic (not covered) indication: cutaneous scar (facial wounds).; Cosmetic (not covered) indication: deep forehead lines.; Cosmetic (not covered) indication: deep nasolabial folds.; Cosmetic (not covered) indication: glabellar lines.; Cosmetic (not covered) indication: hyperkinetic facial lines.; Cosmetic (not covered) indication: wrinkles, frown lines. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT