Treatment of primary axillary, palmar, or gustatory (Frey’s syndrome) hyperhidrosis when all of the following criteria are met: Primary axillary, palmar, and gustatory (Frey’s syndrome) hyperhidrosis.Treatment of palatal myoclonus when the member has disabling symptoms (e.g., intrusive clicking tinnitus) who had an inadequate response to clonazepam, lamotrigine, carbamazepine or valproate Treatment of painful bruxism when the member has had an inadequate response to a night guard and has had an inadequate response to pharmacologic therapy such as diazepam The member has had an inadequate response or experienced intolerance to two anticholinergic medications (e.g., Vesicare, Enablex, Toviaz, Detrol/Detrol LA, Sanctura/Sanctura XR, Ditropan XL ).The member has tried and failed behavioral therapy and.Treatment of overactive bladder with urinary incontinence, urgency, and frequency when all of the following criteria are met: Overactive bladder with urinary incontinence.Treatment of orofacial tardive dyskinesia when conventional therapies have been tried and failed (e.g., benzodiazepines, clozapine, or tetrabenazine) Injection of corticosteroids into trigger points.Injection of local anesthetics into trigger points and.Treatment of myofascial pain syndrome when the member has tried and failed all of the following: Member has signs and symptoms consistent with chronic migraine diagnostic criteria as defined by the International Headache Society (IHS) Beta-adrenergic blocking agents (e.g., metoprolol, propranolol, timolol, atenolol, nadolol).Antiepileptic drugs (AEDs) (e.g., divalproex sodium, topiramate, valproate sodium).Antidepressants (e.g., amitriptyline, venlafaxine).Member completed an adequate trial of (or has a contraindication to) three oral migraine preventative therapies coming from at least 2 of the following classes with a trial of each medication at least 60 days in duration:.Member experiences headaches lasting 4 hours or longer on at least 8 days per month.Member experiences headaches 15 days or more per month.Prevention of chronic migraine when all of the following criteria are met: Treatment of Hirschsprung’s disease with internal sphincter achalasia following endorectal pull through and the member is refractory to laxative therapy Hirschsprung disease with internal sphincter achalasia.Treatment of first bite syndrome when the member has failed relief from analgesics, antidepressants or anticonvulsants Treatment of excessive salivation (chronic sialorrhea or ptyalism) when the member has been refractory to pharmacotherapy (e.g., anticholinergics) Treatment of adults with cervical dystonia (e.g., torticollis) when there is abnormal placement of the head with limited range of motion in the neck Treatment of blepharospasm, including blepharospasm associated with dystonia and benign essential blepharospasm Treatment of chronic anal fissures when the member has not responded to first line therapy such as topical calcium channel blockers or topical nitrates Treatment of achalasia when the member has tried and failed or is a poor candidate for conventional therapy such as pneumatic dilation and surgical myotomy OnabotulinumtoxinA (Botox Brand of Botulinum Toxin Type A)Īetna considers onabotulinumtoxinA (Botox) medically necessary for any of the following indications:.Precertification of botulinum toxin (Botox Dysport Myobloc and Xeomin ) is required of all Aetna participating providers and members in applicable plan designs. Primary axillary, palmar, and gustatory (Frey’s syndrome) hyperhidrosis (Botox and Dysport only).Excessive salivation (chronic sialorrhea/ptyalism).Therefore, Aetna considers Myobloc (rimabotulinumtoxinB) to be medically necessary only for members who have a contraindication, intolerance or ineffective response to the available equivalent alternative botulinum toxin agents: Botox (onabotulinumtoxinA), Dysport (abobotulinumtoxinA), and Xeomin (incobotulinumtoxinA) for the following medically necessary indications: There is a lack of reliable evidence that Myobloc (rimabotulinumtoxinB) is superior to the lower cost botulinum toxin agents: Botox (onabotulinumtoxinA), Dysport (abobotulinumtoxinA), and Xeomin (incobotulinumtoxinA) for the medically necessary indications listed below. Commercial CPB | Medicare CPB Brand Selection for Medically Necessary IndicationsĪs defined in Aetna commercial policies, health care services are not medically necessary when they are more costly than alternative services that are at least as likely to produce equivalent therapeutic or diagnostic results. Myobloc (rimabotulinumtoxinB) brand is more costly to Aetna than other botulinum toxin agents for certain indications.
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