Medical Policy Updates

Notification of Policy Revisions Effective January 14, 2020 (Posted October 15, 2019)

Medical Policy Revision
Botulinum Toxin Injection "Notification"

Added the following to "When Covered" section for chronic migraine headache: "requests for Botox may be approved for members who have had an inadequate response to or are intolerant to a CGRP antagonist, such as fremanezumab, galcanezumab, or erenumab", and for cervical dystonia and upper limb spasticity: "requests for Botox may be approved for members who have had an inadequate response to or are intolerant to Xeomin and Dysport". Under "When Covered," added the following for chronic migraine headache: "Botox will not be used concomitantly with a CGRP antagonist for chronic migraine headache". Updated "Description" section to remove "with onabotulinumtoxinA prior treatment" for Xeomin blepharospasm indication, and added indication for Myobloc for treatment of chronic sialorrhea in adults. Added reference to related pharmacy policy: "CGRP Therapy for Migraine". References added. Medical Director review 9/2019. Notification given 10/1/2019 for effective date 1/1/2020.

Revised wording in "When Covered" section for cervical dystonia to state: "Requests for Botox and Myobloc may be approved for members who have had an inadequate response to or are intolerant to Xeomin and Dysport." Policy remains on notice for effective date 1/14/2020.