Prior Authorization : Services Requiring Prior Authorization

Prior Authorization for OnabotulinumtoxinA (Botox)

Botox is a neurotoxin used to treat a number of diagnoses including (but not limited to) cervical dystonia, limb spasticity, strabismus, chronic migraines, and urinary incontinence.

Botox is covered for members enrolled in BadgerCare Plus and Medicaid. It is not covered for SeniorCare members.

For members enrolled in BadgerCare Plus HMOs, Medicaid SSI HMOs, and most special managed care programs, claims for Botox should be submitted to BadgerCare Plus and Medicaid fee-for-service for reimbursement.

Botox for Use to Treat Chronic Migraines

A dosing range of no greater than 200 units per treatment is considered acceptable for the use of Botox to treat chronic migraines.

Providers Who May Administer Botox To Treat Chronic Migraines

The following licensed and Medicaid-enrolled providers familiar with and experienced in the use of Botox may administer this agent to treat chronic migraines:

• Nurse practitioners
• Physician assistants
• Physicians

When using Botox to treat chronic migraines, the rendering provider is required to follow the procedures for diagnosis-restricted physician-administered drugs.

Claims for Botox to treat chronic migraines are only reimbursable without PA when submitted with one of the approved ICD diagnosis codes.

Clinical Criteria for Coverage of Botox to Treat Chronic Migraines

Clinical criteria for coverage of Botox for the treatment of chronic migraines are all of the following:

• The member is 18 years of age or older.
• The dosing range is no greater than 200 units per treatment.
• The service is ordered by the provider who has evaluated and diagnosed the member as experiencing chronic migraines using the revised International Headache Society criteria for chronic migraines.
• The member has experienced headaches (tension-type and/or migraine) for three or more months that have lasted four or more hours per day on 15 or more days per month, with eight or more headache days per month being migraines/probable migraines (and that are not due to medication overuse or attributed to another causative disorder).
• The member scored a grade indicating moderate to severe disability on the MIDAS test, or on a similar validated tool. The MIDAS test was developed by the American Headache Society for Headache Education.
• The rendering provider has discussed alternative non-pharmacological treatment options with the member, such as behavioral therapies, physical therapies, and lifestyle modifications.
• One of the following is true:
  • The member has tried migraine prophylaxis medications from three or more of the drug categories listed below and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction:
    • Antidepressants
    • Anticonvulsants
    • Beta blockers
    • Calcium channel blockers
    • Other drugs
  • The member has a medical condition that prevents them from trying migraine prophylaxis medications from three or more of the drug categories listed above, or there is a clinically significant drug interaction with a medication the member is currently taking that prevents them from trying migraine prophylaxis medications from three or more of the drug categories listed above.

Note: In order for the member to qualify for the treatment, their medical record must support the clinical criteria outlined, and the medical records must be made available upon audit request.

If one of the ForwardHealth-approved chronic migraine diagnoses is appropriate for the member, but not all of the above clinical criteria are met, the provider may submit a PA request on the PA/PAD form along with clinical documentation explaining the reason for the PA request. Depending on the specific clinical criteria that have not been met, the prescriber is required to submit appropriate clinical documentation, such as the following:

• Peer-reviewed medical literature to support the proven efficacy and safety of the requested use
• Documentation of the clinical rationale to support the medical necessity
• Documentation of previous treatments and detailed reasons why other covered drug treatments were discontinued or not utilized
• Medical records

PA requests for Botox may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Treatment Frequency

If a member meets the clinical criteria for coverage of Botox for the treatment of chronic migraines, ForwardHealth will cover no more than two treatments in six months.

To continue treatment, a member must experience clinically significant and documented improvement in the frequency or duration of chronic migraines using at least one of the following indicators:

• Reduction in acute services, emergency services, or need for rescue treatment for acute chronic migraines
• At least a 40 percent reduction in the frequency, severity, or length of chronic migraines
• Improved assessment score on the MIDAS test or on a similar validated tool
• Reduced use of analgesics

Overall frequency of treatment should not exceed more than one treatment every three months.

Botox for Use to Treat Other Diagnoses

For uses other than the treatment of chronic migraines, Botox is a diagnosis-restricted drug.