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Botulinum Toxins

Botox® (onabotulinumtoxinA)
Myobloc® (rimabotulinumtoxinB)
Dysport®  (abobotulinumtoxinA)
Xeomin® (incobotulinumtoxinA)

January 2017

Therapeutic area - botulinum toxins

Approval Criteria

  • Treatment for the medical uses listed in the tables  or for spasticity, including spasticity in cerebral palsy, or for excessive drooling associated with a neurologic disorder not managed by oral therapy
  • Botox may also be approved for use of severe bruxism, particularly those with associated movement disorders, when all conservative treatments have failed (mouth guard, oral meds, physical therapy)
  • Use of botulinum toxin, type A or type B, will not be approved for cosmetic purposes such as removal of facial wrinkles
  • Botulinum toxin for the treatment of chronic migraine headaches is generally not covered. However, truly exceptional chronic migraine cases will be reviewed for medical necessity on a case by case basis.
  • Authorizations can be granted for up to 12 months. Each subsequent authorization requires documentation verifying the patient’s response to the treatment. The prior authorization will only be granted if the documentation shows a positive response to the treatment.

Botulinum toxins – type A

Brand name Botox® Onabotulinumtoxin A Dysport® Abobotulinumtoxin A Xeomin® Incobotulinumtoxin A
Medical use

Treatment of cervical dystonia in adults to decrease the severity of abnormal head position and neck pain

Treatment of severe primary axillary hyperhidrosis that is inadequately managed with topical agents

Treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorders in patients 12 years of age and above

Treatment of urinary incontinence due to detrusor overactivity associated with a neurologic condition [e.g., spinal cord injury (SCI), multiple sclerosis (MS)] in adults who have an inadequate response to or are intolerant of an anticholinergic medication

Treatment of overactive bladder in adult patients who have an inadequate response to or are intolerant of 3 anticholinergic medications and mirabegron

Treatment of upper and lower limb spasticity in adult patients

Treatment of adults with cervical dystonia 

Treatment of upper limb spasticity in adults

Treatment of lower limb spasticity in pediatric patients 2 years of age and older

Treatment of adults with cervical dystonia to decrease the severity of abnormal head position and neck pain in both botulinum toxin-naïve and previously treated patients

Treatment of adults with blepharospasm who were previously treated with onabotulinumtoxinA (Botox®)

HCPCS code J0585 J0586 J0588
HCPCS code descriptor Injection, onabotulinumtoxinA, 1 unit Injection, abobotulinumtoxinA, 5 units Injection, incobotulinumtoxin A, 1 unit 
Vial sizes 100 units, 200 units  300 units, 500 units 50 units, 100 units

Botulinum toxins – type B

Brand name Myobloc® rimabotulinumtoxinB
Medical uses The treatment of patients with cervical dystonia to reduce the severity of abnormal head position and neck pain
HCPCS Code J0587
HCPCS Code descriptor Injection, rimabotulinumtoxinB, 100 units
Vial sizes 2,500 units, 5,000 units, 10,000 units

Note: Lack of interchangeability among botulinum toxin products

The potency units of the botulinum toxins are specific to the preparation and assay method utilized. Therefore, units of biological activity of one botulinum toxin product cannot be compared to nor converted into units of any other botulinum toxin product.


MHCP Provider Call Center 651-431-2700 or 800-366-5411

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