This version of the policy will become effective 12/16/2019.
The policy has been updated to communicate expanded indications and corresponding diagnosis codes for onabotulinumtoxinA, (Botox® and Botox Cosmetic® [Allergan]), prabotulinumtoxinA-xvfs (Jeuveau™ [Evolus]), rimabotulinumtoxinB (Myobloc® [Solstice Neurosciences, Inc]), abobotulinumtoxinA (Dysport® [Ipsen Biopharmaceuticals]), and incobotulinumtoxinA (Xeomin® [Merz Pharmaceuticals, Raleigh, NC]).
The following codes were ADDED for onabotulinumtoxinA
G25.0 Essential tremor
N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
Dual diagnosis for spasticity of limbs has been added, M62.838 Other muscle spasm (added), I69.398 Other sequelae of cerebral infarction (policy language stroke) – added.
The following codes were REMOVED for onabotulinumtoxinA
G43.821 Menstrual migraine, not intractable, with status migrainosus
G43.829 Menstrual migraine, not intractable, without status migrainosus
G43.831 Menstrual migraine, intractable, with status migrainosus
G43.839 Menstrual migraine, intractable, without status migrainosus
G43.A0 Cyclical vomiting, not intractable
G43.C0 Periodic headache syndromes in child or adult, not intractable
G43.C1 Periodic headache syndromes in child or adult, intractable
G24.01 Drug induced subacute dyskinesia
G24.4 Idiopathic orofacial dystonia
Note: On 10/09/2019 the following revisions were made to the Policy section:
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Policy: 08.00.15e:Off-label Coverage for Prescription Drugs and/or Biologics
Policy: 11.05.07d:Surgical Correction of Strabismus