Botox Criteria Update
Date: 09/15/21
Arizona Complete Health-Complete Care Plan (Medicaid) and Ambetter from Arizona Complete Health (Marketplace) want to provide you with the latest criteria for OnabotulinumtoxinA (Botox). The indication and associated guideline is outlined below. We are also including the actual clinical guideline as a separate attachment with this update.
Please use the Pre-Auth Check Tool on our website to confirm if a specific code(s) requires prior authorization. When checking Medicaid prior authorization requirements please select the Medicaid tool and when checking Ambetter prior authorization requirements please select the Ambetter tool as prior authorization requirements vary based on the line of business.
Indication | Guideline |
|---|---|
Blepharospasm, cervical dystonia, adult spasticity, and headache | Academy of Neurology (2016) |
Migraine prevention | American Academy of Neurology and the American Headache Society. Neurology (2012) |
Laryngeal dystonia | American Academy of Otolaryngology-Head and Neck Surgery Foundation (2018); American Academy of Neurology (2008) |
Oromandibular dystonia | American Academy of Oral Medicine (2018) |
Focal limb dystonia - UE** | American Academy of Neurology (2008) |
Essential tremor - UE | American Academy of Neurology (2008) |
Sialorrhea | American Academy of Cerebral Palsy and Developmental Medicine (AACPDM, 2018); International Parkinson and Movement Disorder Society (2018) |
OAB/urinary incontinence | American Urological Association Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (2014, 2015) |
| Indication | Guideline |
Esophageal achalasia | American College of Gastroenterology (2013) |
HD and IAS achalasia | American Pediatric Surgical Association (2017) |
Chronic anal fissure | American College of Gastroenterology (2014) |
*American Academy of Neurology (AAN) classifies Botox use for hemifacial spasm and motor tics as category C, and notes that data are inadequate to make a recommendation for lower limb dystonia. All other AAN Botox recommendations above are classified as category B - probably effective.
**Policy criteria requiring failure of oral medication for dystonias are limited to dystonias affecting the limbs (see Cloud and Jinnah, 2010).
If you have questions regarding the information contained in this update please contact our Provider Customer Service center at (866) 796-0542 or your Provider Engagement Specialist. If you need contact information for your assigned Provider Engagement, please email AzCHProviderEngagement@azcompletehealth.com.