Medical Policy

Policy Num:       M5.001.026
Policy Name:     Botulinum Toxins
Policy ID:          [M5.001.026] [Ac/MA/M+/ P+ ] [L33274]

Last Review:       September 17, 2025
Next Review:      September 20, 2025
 

Related Policies: Billing and Coding: Botulinum Toxins (A57715)

Botulinum Toxins

Summary

Botulinum is a family of toxins produced by the anaerobic organism Clostridia botulinum. Four formulations have been approved by the U.S. Food and Drug Administration (FDA). Labeled indications of these agents differ; however, all are FDA-approved for treating cervical dystonia in adults. Botulinum toxin products are also used for a range of off-label indications.

For individuals who have dystonia or spasticity resulting in functional impairment and/or pain (eg, interference with joint function, mobility, communication, nutritional intake) who receive botulinum toxin injections, the evidence includes multiple randomized controlled trials (RCTs) and meta-analyses. Relevant outcomes are symptoms, functional outcomes, medication use, and treatment-related morbidity. The data support the efficacy of botulinum toxin for improving dystonia or spasticity in patients with various conditions. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have strabismus who receive botulinum toxin injections, the evidence includes several RCTs. Relevant outcomes are symptoms, functional outcomes, and treatment-related morbidity. RCTs evaluating botulinum toxin have reported mixed findings; treatment with botulinum toxin is a noninvasive alternative to surgery and is associated with fewer harms. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have blepharospasm or facial nerve (cranial nerve VII) disorders who receive botulinum toxin injections, the evidence includes several RCTs. Relevant outcomes are symptoms, functional outcomes, and treatment-related morbidity. RCTs and a systematic review have found symptom improvements in patients treated with botulinum toxin compared with alternative interventions. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have chronic migraine headache who receive botulinum toxin injections, the evidence includes several RCTs and meta-analyses. Relevant outcomes are symptoms, medication use, and treatment-related morbidity. RCTs have reported mixed findings; a meta-analysis found that botulinum toxin reduced the frequency of headaches per month compared with placebo or medication. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have esophageal achalasia who receive botulinum toxin injections, the evidence includes a number of RCTs and a systematic review of RCTs. Relevant outcomes are symptoms, functional outcomes, and treatment-related morbidity. The systematic review found similar efficacy and less harm with botulinum toxin than with pneumatic dilation. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have sialorrhea (drooling) associated with Parkinson disease who receive botulinum toxin injections, the evidence includes several RCTs. Relevant outcomes are symptoms, functional outcomes, and treatment-related morbidity. RCTs have consistently found that botulinum toxin provides benefit. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have sialorrhea (drooling) not associated with Parkinson disease who receive botulinum toxin injections, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms, functional outcomes, and treatment-related morbidity. Available individual RCTs are small and have not consistently found a clinically meaningful improvement with botulinum toxin therapy. In several trials, rates of adverse events were notably high, making the risk-benefit ratio of botulinum toxin therapy uncertain. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have internal anal sphincter achalasia who receive botulinum toxin injections, the evidence includes 2 RCTs and multiple nonrandomized studies, which have been summarized in a systematic reviews and meta-analysis. Relevant outcomes are symptoms, health status measures, and treatment-related morbidity. In a systematic review of nonrandomized studies comparing botulinum toxin injection with myectomy, outcomes were more favorable after surgery. Though the 2 RCTs reported temporary improvement in symptoms after botulinum toxin injections, methodologic limitations, including small sample sizes, lack of blinded assessments, and lack of use of validated outcome measures, limit the interpretation of these RCTs. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have chronic anal fissure who receive botulinum toxin injections, the evidence includes a number of RCTs and a systematic review. Relevant outcomes are symptoms, health status measures, and treatment-related morbidity. Studies have found similar efficacy with botulinum toxin or surgery, and less potential harm with toxin injections. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have urinary incontinence due to detrusor overactivity associated with overactive bladder or with neurogenic causes who receive botulinum toxin injections, the evidence includes numerous RCTs. Relevant outcomes are symptoms, medication use, and treatment-related morbidity. Studies have shown that botulinum toxin is effective at reducing symptoms in patients unresponsive to anticholinergic medications. There are adverse events associated with botulinum toxin (eg, urinary retention, urinary tract infection), but patients may find that benefits outweigh harms. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals with urologic issues other than detrusor overactivity or overactive bladder (eg, detrusor sphincter dyssynergia, benign prostatic hyperplasia, interstitial cystitis) who receive botulinum toxin injections, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms, medication use, and treatment-related morbidity. Available RCTs for these conditions are small and have reported mixed findings on the benefit of botulinum toxin. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have other indications (eg, tremors such as benign essential tremor [upper extremity], chronic low back pain, lateral epicondylitis, joint pain, myofascial pain syndrome, temporomandibular joint disorders, trigeminal neuralgia, pain after hemorrhoidectomy, facial wound healing, pelvic and genital pain in women, neuropathic pain, tinnitus, pain associated with breast reconstruction after mastectomy, Hirschsprung disease, gastroparesis, and depression) who receive botulinum toxin injections, evidence includes case series or a few small, flawed RCTs. Relevant outcomes are symptoms, functional outcomes, medication use, and treatment-related morbidity. Evidence of benefit from large, well-conducted RCTs is lacking for these indications. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals with Hirschsprung disease who develop obstructive symptoms after a pull-through operation who receive botulinum toxin injections, the evidence includes 3 case series. Relevant outcomes are symptoms, health status measures, and treatment-related morbidity. The 3 case series included a total of 73 patients with median follow-up of more than 7 years. In 2 out of the 3 published case series consistent short-term responses were reported in more than 75% of patients. Long- term follow-up is suggestive of durability of response. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Policy Statements

The use of botulinum toxin may be considered medically necessary for the following:

•         Cervical dystonia (spasmodic torticollis; applicable whether congenital, due to child birth injury, or traumatic injury). For this use, cervical dystonia must be associated with sustained head tilt or abnormal posturing with limited range of motion in the neck AND a history of recurrent involuntary contraction of one or more of the muscles of the neck, eg, sternocleidomastoid, splenius, trapezius, or posterior cervical muscles.^a (See additional details in Policy Guidelines section.)

•         Upper-limb spasticity^a

•         Dystonia/spasticity resulting in functional impairment (interference with joint function, mobility, communication, nutritional intake) and/or pain in patients with any of the following:

o    Focal dystonias:

§  Focal upper-limb dystonia (eg, organic writer's cramp)

§  Oromandibular dystonia (orofacial dyskinesia, Meige syndrome)

§  Laryngeal dystonia (adductor spasmodic dysphonia)

§  Idiopathic (primary or genetic) torsion dystonia

§  Symptomatic (acquired) torsion dystonia

o    Spastic conditions

§  Cerebral palsy

§  Spasticity related to stroke

§  Acquired spinal cord or brain injury

§  Hereditary spastic paraparesis

§  Spastic hemiplegia

§  Neuromyelitis optica

§  Multiple sclerosis or Schilder disease

•         Strabismus^a

•         Blepharospasm or facial nerve (VII) disorders (including hemifacial spasm)^a

•         Prevention (treatment) of chronic migraine headache in the following situations^a:

o    Initial 6-month trial: Adults who:

§  meet International Classification of Headache Disorders diagnostic criteria for chronic migraine headache (see Policy Guidelines) and

§  have symptoms that persist despite adequate trials of at least 2 agents from different classes of medications used in the treatment of chronic migraine headaches (eg, antidepressants, antihypertensives, antiepileptics). Patients who have contraindications to preventive medications are not required to undergo a trial of these agents.

o    Continuing treatment beyond 6 months:

§  Migraine headache frequency reduced by at least 7 days per month compared with pretreatment level, or

§  Migraine headache duration reduced at least 100 hours per month compared with pretreatment level.

•         Esophageal achalasia in patients who have not responded to dilation therapy or who are considered poor surgical candidates

•         Sialorrhea (drooling) associated with Parkinson disease

•         Chronic anal fissure

•         Urinary incontinence due to detrusor overactivity associated with neurogenic causes (eg, spinal cord injury, multiple sclerosis) in patients unresponsive to or intolerant of anticholinergics^a

•         Overactive bladder in adults unresponsive to or intolerant of anticholinergics.^a

^a Food and Drug Administration-approved indication for at least one of the agents.

With the exception of cosmetic indications, the use of botulinum toxin is considered investigational for all other indications not specifically mentioned above, including, but not limited to:

•         headaches, except as noted above for prevention (treatment) of chronic migraine headache

•         sialorrhea (drooling) except that associated with Parkinson disease

•         internal anal sphincter achalasia

•         benign prostatic hyperplasia

•         interstitial cystitis

•         detrusor sphincteric dyssynergia (after spinal cord injury)

•         chronic low back pain

•         joint pain

•         mechanical neck disorders

•         neuropathic pain

•         myofascial pain syndrome

•         temporomandibular joint disorders

•         trigeminal neuralgia

•         pain after hemorrhoidectomy or lumpectomy

•         tremors such as benign essential tremor (upper extremity)

•         tinnitus

•         chronic motor tic disorder and tics associated with Tourette syndrome (motor tics)

•         lateral epicondylitis

•         prevention of pain associated with breast reconstruction after mastectomy

•         Hirschsprung disease

•         gastroparesis

•         facial wound healing

•         depression.

The use of botulinum toxin may be considered investigational as a treatment of wrinkles or other cosmetic indications.

The use of assays to detect antibodies to botulinum toxin is considered investigational.

Policy Guidelines

Cervical dystonia is a movement disorder (nervous system disease) characterized by sustained muscle contractions. This results in involuntary, abnormal, squeezing, and twisting muscle contractions in the head and neck region. These contractions can cause sustained abnormal positions or posturing. Sideways or lateral rotation of the head and twisting of the neck are the most common findings in cervical dystonia. Muscle hypertrophy occurs in most patients. When using botulinum toxin to treat cervical dystonia, postural disturbance and pain must be of such severity as to interfere with activities of daily living; and the symptoms must have been unresponsive to a trial of standard conservative therapy. In addition, before using botulinum toxin, alternative causes of symptoms (eg, cervicogenic headaches) must have been considered and excluded.

International Classification of Headache Disorders (ICHD-3) diagnostic criteria for chronic migraine headache include the following:

Headaches at least 15 days per month for more than 3 months; have features of migraine headache on at least 8 days.

Features of migraine headache:

•         Lasts 4 to 72 hours;

•         Has at least 2 of the following 4 characteristics:

o    Unilateral

o    Pulsating

o    Moderate or severe pain intensity

o    Aggravates or causes avoidance of routine physical activity

•         Associated with:

o    Nausea and/or vomiting

o    Photophobia and phonophobia.

(In ICHD-2, absence of medication overuse was one of the diagnostic criteria for chronic migraine. In the ICHD-3, this criterion was removed from the chronic migraine diagnosis and "medication overuse headache" is now a separate diagnostic category.)

Continuing treatment with botulinum toxin beyond 6 months for chronic migraine includes the following.

The policy includes the requirement that migraine headache frequency be reduced by at least 7 days per month compared with pretreatment level, or that migraine headache duration be reduced by at least 100 hours per month compared with pretreatment level in order to continue treatment beyond 6 months. The 7 days per month represents a 50% reduction in migraine days for patients who have the lowest possible number of migraine days (ie, 15) that would allow them to meet the ICHD-3 diagnostic criteria fewest chronic migraine. A 50% reduction in frequency is a common outcome measure for assessing the efficacy of headache treatments and was one of the end points of the PREEMPT study.

DOSAGE/ADMINISTRATION

REQUIRED MEDICAL INFORMATION

Prescription or treatment plan with details of: area of treatment, dosing and frequency planned.

Diagnosis and medical necessity: duration and nature of illness, comorbid conditions, previous treatments and response.

In the case of continuing treatment (beyond 6 months) documentation of response to Botox compared to pretreatment level.

EXCLUSION CRITERIA

BENEFIT APPLICATION

Triple S Preferred drugs

Triple-S Salud will consider Dysport, Xeomin, and Botox as preferred agents for covered conditions. 

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

OTHER CRITERIA

Off-Label Indications Supported by Evidence-Based Guidelines

Botulinum toxin is used therapeutically to reduce pathologic muscle contraction. Health outcomes of interest are improved function and improved quality of life.

Gastrointestinal

Achalasia
The American College of Gastroenterology has provided evidence based clinical practice guidelines for the diagnosis and management of achalasia. Achalasia is a condition where the muscles in the lower part of the esophagus do not relax and prevent the passage of food. Botulinum toxin has a strong recommendation based on moderate quality evidence in patients who are not candidates for pneumatic dilation (PD) or surgical myotomy.⁴ Serious side effects are rare. In comparative effectiveness studies, PD was found to be superior to botulinum toxin, demonstrating PD is more effective in the long term, and therefore only patients who are not candidates for pneumatic dilation, or surgical myotomy, are eligible for botulinum toxin.

Technical Assessments
A Cochrane database review of 6 studies included 178 patients and discovered no significant difference in remission between PD and botulinum toxin treatment within 4 weeks of the initial intervention. Three studies included in the review had 12-month data with remission in 33 of 47 PD patients compared with 11 of 43 botulinum toxin patients (relative risk of 2.67, 95% confidence interval 1.58–4.52). These outcomes provide strong evidence that PD is more successful than botulinum toxin in the long term for patients with achalasia.

Chronic Anal Fissure
Anal fissure is defined as an ulcer-like, longitudinal tear in the midline of the anal canal, distal to the dentate line. Treatments for anal fissure lean heavily on adaptation from the American Society of Colon and Rectal Surgeons Practice Parameters from the most recent published guidelines in 2010 and 2011 and are supplemented with subsequent publications through 2013.⁵ Generally, treatment for chronic anal fissure is targeted at reducing the sphincter spasms caused by this condition. Recommended therapy includes topical medications like calcium channel blockers or nitrates. For patients who do not respond to conservative or pharmacologic treatment, local injections of botulinum toxin are strongly recommended for relief of painful spasms. Surgery (internal anal sphincterotomy) is recommended for medically refractory situations.

Wald et al.⁵ released the American College of Gastroenterology practice guideline for management of benign anorectal disorders which discuss the definitions, diagnostic criteria, differential diagnoses, and treatments of a set of benign disorders of anorectal function and/or structure. Studies⁵ show that injection of botulinum toxin into the internal anal sphincter allows healing in 60% to 80% of fissures, and at a greater rate than a placebo. Usual side effects include temporary incontinence of flatus in up to 18%, and of stool in 5%. Relapse may occur in up to 42%, however patients have shown similar outcomes to initial therapy.

Currently, a consensus has not been reached on dosage, exact site of administration, number of injections, or effectiveness. Greater doses may increase healing and are considered as safe as lower doses. The effects of botulinum toxin may be potentiated by topical nitrate medications in patients with refractory anal fissure. Botulinum toxin is reserved for patients who fail pharmacologic treatment with nitrates or calcium channel blockers. Lateral internal sphincterotomy (LIS) is recommended for patients who have failed botulinum toxin injection therapy.

Other benign anorectal disorders which include defecatory disorders, fecal incontinence and chronic proctalgia lack evidence for botulinum toxin administration.

Neurology
The American Academy of Neurology (AAN)¹² has produced a clinical practice guideline process manual that includes a discussion regarding elements of recommendations and levels of evidence (see tables below).

Blepharospasm
The American Academy of Neurology has provided recommendations for the use of botulinum neurotoxin in blepharospasm based on the following studies:

One Class II and one Class III study⁶ compared two different serotype A botulinum neurotoxins (Botox® and Dysport®). In the Class II study, 212 participants were assessed in a crossover design using a 4:1 dose ratio of Dysport® to Botox®. The primary clinical outcome, duration of effect, was similar for the two botulinum neurotoxins. The Class III trial, a parallel design of 42 patients without blinded raters, used a dose ratio of 4:1. Duration of action was the primary clinical outcome, and this outcome and others including number of booster doses needed, latency of effect, clinical efficacy, and adverse reactions were comparable for the two botulinum toxin products. A Class I trial performed a comparison of Xeomin® and Botox® injecting equal doses in 300 study participants (256 participants finished the trial). Results showed identical effectiveness and side effects.

The conclusion for these studies indicate Botox® and Xeomin® have level B evidence, Dysport® has level C evidence. These studies signify that following dose modifications, Botox® and Xeomin® may be equal and Botox® and Dysport® may be comparable for the treatment of blepharospasm.

Hemifacial Spasm
Hemifacial spasm is illustrated by a combination of unilateral clonic and tonic spasms of the muscles innervated by the facial nerve. Treatment choices include oral pharmacologic treatments (including carbamazepine, baclofen, and benzodiazepine) that have limited effectiveness, and microvascular decompression of the facial nerve, which is a highly invasive technique.

A Class II study⁶ comprised of 11 patients was a prospective, blinded trial with four arms: a random dose based on clinical experience of between 2.5 and 10 units of BoNT-A (Botox®), half the dose, double the dose, and saline placebo. Patients went through the four treatment arms in random order. Utilization of a clinical scale to rate videotapes and a patient subjective scale, 84% had objective improvement with a minimum of one of the active doses with a tendency for an improved response with higher dose; only one participant improved on placebo. Seventy-nine percent described subjective improvement lasting an average of 2.8 months with active treatment. The principal side effect was weakness of the face, generally mild (97%). Other side effects included bruising, diplopia, ptosis, and headache.

A Class III study⁶, a double-blind, prospective, parallel design including only four participants per group used individualized therapy (dose range 2.5 to 40 units) with BoNT-A (Botox®) in the active arm. In addition, 93 patients studied in an open label fashion were reported. More improvement was shown on a clinical scale with BoNT than with a saline placebo. Improvement continued an average of 3.8 months. Side effects, reported in 63% of participants, were usually mild and involved dry eye, mouth droop, and ptosis.

One Class II study⁶ contrasted Botox® and Dysport® in a parallel design without placebo control or blinded raters. A dose ratio of 4:1 was used for Dysport® to Botox®. The primary clinical outcome (duration of action) and other clinical outcomes (number of booster doses needed, latency of effect, clinical efficacy, and frequency of adverse reactions) were comparable for the two products. Therapeutic effects lasted 2.6–3.0 months.

The conclusion for these studies signifies botulinum neurotoxin may be considered as a treatment for hemifacial spasm. Botox® and Dysport® have level C evidence and after dosage modification, are comparable in effectiveness.

Focal limb dystonia
Focal hand dystonia is also referred to as writer’s cramp, other occupational hand dystonia, and non-task-specific hand dystonia. Currently, no effective alternative medical or proven surgical therapies have been established for focal limb dystonia.

A Class I trial⁶ randomized 40 study participants with writer’s cramp in a double-blind design for botulinum neurotoxin (BoNT) or an equal amount of saline placebo. Clinical assessment was utilized in selecting the muscle to be injected. Study participants with insufficient or no response were offered a second injection one month later. The chief outcome measure was the patient’s indicated request to continue injection therapy. In patients randomized to BoNT, 70% requested to maintain treatment in comparison to 32% of those who received a placebo (p = 0.03). Patients injected with BoNT also had considerable improvement in comparison to patients who had been given a placebo in secondary clinical outcome measures including a visual analog scale, symptoms severity scale, writer’s cramp rating scale, and assessment of writing speed, but not in the functional status scale. The only side effects reported were temporary weakness and pain at the injection site.

One Class II trial, a prospective, double-blind, crossover study⁶ comprised 17 study participants with several forms of limb dystonia, including lower extremity (3 patients) and secondary dystonia (4 patients). Study participants were given a series of four injections in arbitrary order, one with a dose of BoNT that the investigators judged to be “optimal,” one at half the optimal dose, one at double the dose, and one with saline placebo. Per a patient subjective scale, 82% of patients who received BoNT experienced improvement compared to 6% (one patient) who received placebo. Using physician rating of videotapes, 59% of patients experienced improvement with active treatment and 38% with placebo (not significant). A dose-response association for improvement was not evident. A considerable degree of inter-observer inconsistency was shown, which was attributed to an inadequate outcome evaluation. The principal side effect after BoNT injections was focal weakness (53%) with increased probability with higher doses. Weakness was experienced with 13% of placebo injections and additional adverse effects involved muscle stiffness, pain, and malaise.

Another Class II study⁶ utilized a placebo-controlled, double-blind, crossover design for 20 individuals with writer’s cramp. Clinical assessment was utilized in selecting the muscle to be injected and the dose of BoNT-A was founded on investigator experience. Outcome evaluations included assessment of writing speed, accuracy, writing samples, and patients’ subjective report. There was substantial improvement with BoNT therapy in the objective measures, but not in patients’ own evaluations. The only adverse effect was focal weakness, although this was severe enough to worsen pen control in one participant. This study only evaluated the first active therapy session for study participants; therefore, the therapeutic effects achieved were not optimal.

An additional Class II trial⁶ was a double-blind, placebo-controlled, crossover design with 10 study participants with focal hand dystonia. Muscles and BoNT-A (Botox®) doses were selected and optimized during a time of open treatment before the trial. Outcome measures were based on study participant’s subjective ratings and observer ratings of videotapes taken during actions relevant to the individual dystonia. Eight participants had improved subjective ratings and six had improved videotape ratings with BoNT in comparison with placebo. Weakness was noted in the injected muscles of 80% of study participants with active treatment.

Three Class II studies⁶ assessed technical issues of BoNT administration. In one trial, a blinded, randomized, crossover design was utilized to contrast continuous muscle activation to immobilization immediately following BoNT injection. Blinded assessment of handgrip strength and writing showed a substantial increase in focal weakness with continuous muscle activity, but no subjective or objective improvement in writing. In a different Class II study, participants were randomized to one of two muscle localization methods; electromyography (EMG) recording or electrical stimulation. Injections guided by both techniques were similarly effective in producing weakness in the target muscle. In a third trial, the precision of muscle localization with and without EMG was assessed. In needle placements established on surface anatomy, 37% were localized in the targeted muscle.

The therapy for focal limb dystonia with BoNT is challenging, especially in reaching adequate neuromuscular blockade to relieve dystonic movements without initiating excessive muscle weakness.

The conclusion for these studies signifies Botox® has level B evidence and should be considered as a treatment option for focal limb dystonia.

Laryngeal dystonia
Laryngeal dystonia (spasmodic dysphonia) commonly presents as adductor type (ADSD) and less commonly as abductor type (ABSD). The voice of an individual with ADSD is described as strained or strangled, while ABSD generates a weak and breathy voice. Currently, no effective alternative medical or surgical therapies have been established for spasmodic dysphonia.

One Class I trial⁶ of botulinum neurotoxin (BoNT) for 13 study participants with ADSD, a double-blind, randomized, parallel group study, compared seven patients who received BoNT with six patients who received saline. Outcome measures comprised instrumental quantitative measures of voice function and patient ratings. Substantial benefit was achieved in the study participants who received BoNT (p = 0.01).

One Class III trial⁶ discovered that adding voice therapy after BoNT therapy in ADSD patients extended improvements from the BoNT treatment. Another study discovered that resting the voice for 30 minutes following the BoNT injection extended the therapeutic effects of BoNT. One Class III study of 15 participants with ABSD did not observe a noteworthy distinction between using percutaneous or endoscopic injection technique.

The conclusion for these studies signifies Botox® has level B evidence and should be recommended as a treatment option for adductor spasmodic dysphonia (ADSD); however, there is inadequate evidence to support the effectiveness for botulinum neurotoxin in abductor spasmodic dysphonia (ABSD).

Chronic tics
Tics, generally linked with Tourette syndrome, are characterized as short, sporadic movements (motor tics) or sounds (vocal or phonic tics), generally led by a premonitory sensation. Current treatment includes anti-dopaminergic drugs (neuroleptics) which are normally successful for multifocal tics. However, the side effects are considered unfavorable especially in individuals with focal tics like blinking, blepharospasm, head jerking, neck twisting, and loud vocalizations, including the involuntary and repetitive use of obscene language.

In preliminary open label Class IV trials,⁶ the muscles involved in the motor and phonic tics were injected with botulinum neurotoxin (BoNT) and showed an adequate to significant decrease in the strength and occurrence of the tics, and almost full elimination of the premonitory sensation. In a Class IV trial of 35 study participants treated in 115 sessions for bothersome or incapacitating tics, the average peak effect response was 2.8 (range 0=no effect, 4=marked improvement in both severity and function). The average length of improvement was 3.4 months (up to 10.5). Dormancy to start of improvement was 3.8 days (up to 10). Twenty-one participants out of 25 (84%) with significant premonitory sensory symptoms obtained noticeable relief of these symptoms with BoNT (average improvement 70.6%).

A class II trial⁶ with 18 study participants with simple motor tics achieved a 39% decrease in the number of tics per minute in 2 weeks following BoNT injection in comparison to a 6% rise in the placebo participants (p=0.004). Also, a 0.46 decrease in “urge scores” with BoNT in comparison to a 0.49 rise in the placebo participants (p=0.02). This underpowered study was unable to reveal sufficient differences in measured variables like severity score, tic suppression, pain, and patient global impression. The maximum results derived from BoNT may not have been realized at 2 weeks. Also, it was noted that the study participants did not score themselves as considerably compromised because of their tics, so their symptoms may have been reasonably mild at baseline.

The conclusion for these studies indicates Botox® has level C evidence and may be effective for the treatment of motor tics (one Class II study). There is insufficient data to conclude the effectiveness of BoNT in phonic tics (one Class IV study).

Pringsheim et al⁸ provided a systematic review of the literature to make recommendations on the assessment and management of tics in individuals with Tourette syndrome (TS) and chronic tic disorders. A multidisciplinary panel consisting of 9 physicians, 2 psychologists, and 2 patient representatives developed practice recommendations, integrating findings from a systematic review and following an Institute of Medicine–compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence.

The systematic review integrates the evidence supporting the effectiveness and detriments of medical, behavioral, and neurostimulation treatments for tics. The treatment of tics must be personalized and based on collaborative determinations among patients, caregivers, and clinicians. Many individuals with tic disorders have psychiatric comorbidities, which require clinicians to set treatment priorities. The management of comorbid conditions is of chief concern in determining treatment options for tics in individuals with TS. Medications, behavioral therapy, and neurostimulation have been shown to significantly decrease tics; however, these treatments seldom fully terminate tics.

Comprehensive Behavioral Intervention for Tics (CBIT) is recommended as an initial treatment option for individuals with tics causing psychosocial or physical impairment provided that the individual is motivated to participate in treatment (Level B). Other behavioral interventions may be recommended if CBIT is not available, such as exposure and response prevention (Level C).

The literature shows that botulinum toxin injections with onabotulinumtoxinA are probably more likely than a placebo to reduce tic severity in adolescents and adults. Botulinum toxin injections may also improve premonitory urges. OnabotulinumtoxinA is associated with greater rates of weakness relative to placebo. Also, a common side effect of injecting botulinum toxin in the laryngeal muscles for vocal tics is hypophonia. Botulinum toxin effects generally last for 12-16 weeks, after which injections would need to be repeated.

Recommendations based on this study include: 1) Botulinum toxin injections are recommended for the treatment of adolescents and adults with localized and bothersome simple motor tics when the benefits of treatment outweigh the risks (Level C). 2) Botulinum toxin injections are recommended for the treatment of older adolescents and adults with severely disabling or aggressive vocal tics when the benefits of treatment outweigh the risks (Level C). In addition, providers must advise patients with tics that treatment with botulinum toxin may cause temporary weakness and hypophonia.

Essential hand tremor
Tremor, an involuntary, rhythmic movement generated by alternating or synchronous contractions of antagonistic muscles is a common movement disorder. While propranolol and primidone normally improve mild or moderate essential tremor, pharmacotherapy is typically not adequate to control a high-amplitude tremor that disrupts activities of daily living. In patients with disabling tremor, local injection of botulinum neurotoxin (BoNT) may be utilized prior to contemplating more aggressive intervention such as thalamic deep brain stimulation.

A Class II placebo-controlled trial⁶ assessed 25 study participants with hand tremor of 2 (moderate) to 4 (severe) on the tremor severity rating scale. Patients were randomized to be given either 50 units of BoNT-A (Botox®) or placebo injections into the wrist flexors and extensors of the dominant limb. If study participants failed to respond to the first injection, another injection of 100 units could be administered 4 weeks later. Rest, postural, and kinetic tremor were assessed at 2 to 4-week intervals over a 16-week period, using tremor severity rating scales, accelerometry, and evaluations of improvement and disability. There was substantial improvement on the tremor severity rating scale 4 weeks following injection in participants treated with BoNT as compared to placebo, and this improvement was maintained for the length of the study. Four weeks following injection, 75% of BoNT-treated study participants versus 27% of placebo-treated patients (p < 0.05) conveyed mild to moderate improvement. While trends were observed for some elements, functional rating scales did not improve. Postural accelerometry measurements revealed a 30% decrease in amplitude in 9 of 12 BoNT-treated patients and in 1 of 9 placebo-treated patients (p < 0.05). While all patients treated with BoNT reported some degree of finger weakness, no severe, irreversible, or unexpected adverse events transpired.

Comparable results occurred in another Class II multicenter, double-blind, controlled study⁶ that used a comparable protocol and included 133 study participants with essential tremor. Participants were randomized to have 50 or 100 units of Botox® injected into wrist flexors and extensors and were then followed for 4 months. The trial revealed substantial improvement in postural tremor, however only minimal improvement in kinetic tremor and functional evaluations.

The study design of both Class II studies restricts their applicability to clinical practice. Both studies utilized a rigid treatment protocol that employed a fixed BoNT dose and a predetermined set of muscles. In practice, dosages and injected muscles are frequently tailored for a patient based on their tremor pattern.

A Class II study⁶ of only 10 patients with head tremor failed to demonstrate a statistically significant benefit in BoNT-treated patients. Two Class IV open-label studies in voice tremor showed modest improvement from baseline in objective acoustic and subjective measures following unilateral or bilateral BoNT injection.

The conclusion for these studies indicates BoNT injection of forearm muscles may be helpful in reducing the tremor amplitude in patients with essential hand tremor. The benefits must be considered in conjunction with the common adverse effect of muscle weakness associated with BoNT injection. Existing data is insufficient to draw a conclusion on the use of BoNT in the treatment of head and voice tremor. Botox® has level C evidence and should be considered as a treatment option for essential hand tremor in patients with a high amplitude tremor that disrupts activities of daily living and have had an inadequate response to oral agents including propranolol and primidone.

Oromandibular Dystonia
Hassel and Charles⁷ conducted a systematic literature review to give a summary of the history of oromandibular dystonia, botulinum neurotoxin (BoNT), and the utilization of BoNT to treat this focal cranial dystonia. Oromandibular dystonia (OMD) has various treatment choices consisting of BoNT therapy, medication, and surgical intervention. Botulinum neurotoxin is commonly recognized as a first-line therapy.

The effectiveness of medication therapy is limited and does not show the same level of value when compared to BoNT. Oral medication treatments are also restricted by systemic side effects that are not typically experienced with botulinum toxin. Benzodiazepine use is also problematic due to potential tolerance and addiction.

For the treatment of OMD, OnaBoNT/A (Botox®) and aboBoNT/A (Dysport®) carry the highest evidence (level of evidence C for both). While IncoBoNT/A (Xeomin®) and RimaBoNT/B (Myobloc®) have insufficient evidence to support therapy for OMD (level of evidence U for both).

Practice Guidelines and Position Statements

Botulinum toxin can improve quality of life through reducing muscle rigidity and contraction and is a treatment for voluntary and involuntary muscle dysfunction. Reduction of painful contractions is important for an improved quality of life.

Dosing and frequency are important considerations. While botulinum toxins have a fairly wide therapeutic window, all botulinum toxin products have a black box warning regarding the potential for distant spread of toxin effect. These symptoms can occur hours to weeks after administration. Symptoms may include swallowing and breathing difficulties which can be life threatening and can lead to death. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults, particularly in those patients who have an underlying condition that would predispose them to these symptoms.^9,10,11 Therefore, the lowest effective dose that produces the desired clinical effect should be used. Treatment effect can last from twelve to sixteen weeks, with labeled use suggesting a minimum interval of twelve weeks. Dosing frequency should be at the longest interval that produces the desired clinical effect.

Medical utilization of botulinum toxins has increased in the past 30 years with an extensive track record of safety and efficacy.¹ The mechanism of action is well understood. However, the benefits of botulinum toxin must be balanced with the risk. Professional societies have evidence based guideline recommendations to assist providers in maximizing patient outcomes.

There are important differences between the botulinum toxin preparations that include potency and duration of effect. They are chemically, pharmacologically and clinically distinct and are not interchangeable.

Achalasia
Current evidence based guidelines indicate that botulinum toxin therapy for achalasia is confined to circumstances where pneumatic dilation (PD) and surgical myotomy are not considered suitable options due to inherent patient-related risks. In addition to the current guidelines, the IBM Micromedex® compendium DrugDex® lends support for Botox® as an off-label treatment of achalasia in adults.¹³ Therefore, off-label coverage has been extended for Botox® consistent with current evidence based guidelines.

Chronic anal fissure
Current evidenced-based recommendations indicate chronic anal fissure should be treated with topical medications like calcium channel blockers or nitrates. In situations where patients do not respond to conservative or pharmacologic treatment, local injections of botulinum toxin have been shown to be as effective in healing fissures and are therefore recommended as an alternative treatment. Thus, consistent with evidence based guidelines, off-label coverage has been extended for Botox® as a treatment option for chronic anal fissure in patients with inadequate response to conservative or pharmacologic treatment.

Blepharospasm
Studies show Botox® and Xeomin® may be comparable for the treatment of blepharospasm following dose modification. Studies signify Botox® and Dysport® may be equivalent for the treatment of blepharospasm. Dysport® has backing in the IBM Micromedex® compendium DrugDex® for off-label treatment of blepharospasm in adults.¹³ Accordingly, off-label coverage has been extended for Dysport® for the treatment of blepharospasm in adults.

Hemifacial spasm
The literature indicates botulinum neurotoxin may be considered as a treatment for hemifacial spasm with minimal side effects. Studies show Botox® and Dysport®, after dosage modification, may be equal in effectiveness. Botox® and Dysport® have additional support in the IBM Micromedex® compendium DrugDex® for off-label treatment of hemifacial spasm in adults.¹³ Subsequently, off-label coverage has been extended for Botox® and Dysport® as a treatment of hemifacial spasm in adults.

Focal limb dystonia
Currently, no effective alternative medical or proven surgical therapies have been established for focal limb dystonia. Studies signify botulinum neurotoxin should be considered as a treatment option for focal hand dystonia, also referred to as writer’s cramp. Therefore, consistent with evidence based guidelines, off-label coverage has been extended for Botox® as a treatment of focal limb dystonia.

Laryngeal dystonia
Laryngeal dystonia (spasmodic dysphonia) commonly presents as adductor type (ADSD) and less commonly as abductor type of spasmodic dysphonia (ABSD). Presently, no effective alternative medical or surgical therapies have been established for spasmodic dysphonia. Studies show botulinum neurotoxin should be recommended as a treatment option for adductor spasmodic dysphonia (ADSD); however, there is inadequate evidence to support the effectiveness for botulinum neurotoxin in abductor spasmodic dysphonia (ABSD). Botox® has support in the IBM Micromedex® compendium DrugDex® for off-label treatment of spastic dysphonia in adults.¹³ Consequently, consistent with evidence based guidelines, off-label coverage has been extended for Botox®.

Essential hand tremor
Studies indicate botulinum neurotoxin injection of forearm muscles may be helpful in reducing the tremor amplitude in patients with a high amplitude essential hand tremor that disrupts activities of daily living and have had an inadequate response to oral agents including propranolol and primidone. Therefore, consistent with evidence based guidelines, off-label coverage has been extended for Botox® as a treatment for essential hand tremor for patients with a high amplitude tremor that disrupts activities of daily living and have had an inadequate response to oral pharmacotherapy such as propranolol and primidone.

Oromandibular dystonia (OMD)
Oromandibular dystonia (OMD) has various treatment choices consisting of botulinum toxin therapy, medication, and surgical intervention. Medications, like anticholinergics (trihexyphenidyl and benztropine), benzodiazepines, VMAT2 inhibitors (tetrabenazine), levodopa, and baclofen, have been utilized with varying success. The effectiveness of medication therapy is limited and does not show the same level of value when compared to botulinum toxin. Oral medication treatments are also restricted by systemic side effects that are not typically experienced with botulinum toxin.

Current practice guidelines for botulinum toxins show support for Botox® and Dysport® for the treatment of OMD. In addition to the literature, Botox® has support in the IBM Micromedex® compendium DrugDex® for off-label treatment of isolated oromandibular dystonia in adults.¹³ Thus, consistent with evidence based guidelines, off-label coverage has been extended for Botox® and Dysport® as a treatment for isolated oromandibular dystonia in adults.

Motor tics and disabling or aggressive vocal tics
The treatment of tics must be personalized and based on collaborative determinations among patients, caregivers, and clinicians. Many individuals with tic disorders have psychiatric comorbidities, which require clinicians to set treatment priorities. The management of comorbid conditions is of chief concern in determining treatment options for tics in individuals with TS. Medications, behavioral therapy, and neurostimulation have been shown to significantly decrease tics; however, these treatments seldom fully terminate tics. Evidence based guidelines indicate: 1) OnabotulinumtoxinA (Botox®) injections are recommended for the treatment of adolescents and adults with localized and bothersome simple motor tics when the benefits of treatment outweigh the risks; and 2) OnabotulinumtoxinA (Botox®) injections are recommended for the treatment of older adolescents and adults with severely disabling or aggressive vocal tics when the benefits of treatment outweigh the risks. In addition to the current guidelines, the IBM Micromedex® compendium DrugDex®¹³ lends support for Botox® as an off-label treatment of Gilles de la Tourette’s syndrome in adults. Therefore, off-label coverage has been extended for Botox® consistent with current evidence based guidelines.

The quality of evidence in the literature is insufficient to support botulinum toxin injection for the treatment of defecatory disorders (DD), chronic proctalgia, phonic tics, head tremor, and voice tremor at this time. Further research is needed to clarify the utility and efficacy of botulinum toxin therapy for these conditions.

Medicare National Coverage

CMS National Coverage Policy

This Meidcal Polciy supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for botulinum toxins. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for botulinum toxins and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site. 

Internet Only Manual (IOM) Citations: 

CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
Chapter 1, Section 30 Drugs and Biologicals
Chapter 6, Section 20.5.2 Coverage of Outpatient Therapeutic Services Incident to a Physician’s Service Furnished on or After January 1, 2010
Chapter 15, Section 50 Drugs and Biologicals, Section 60 Services and Supplies
Chapter 16, Section 120 Cosmetic Surgery
CMS IOM Publication 100-08, Medicare Program Integrity Manual,
Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD 
Social Security Act (Title XVIII) Standard References:  

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1862(a)(10) excludes coverage for cosmetic surgery.
Title XVIII of the Social Security Act, Section 1861(t). This section addresses drugs and biologicals definitions.

Ongoing and Unpublished Clinical Trials

Some currently ongoing and unpublished trials that might influence this review are listed in Table 11.

Table 11. Summary of Key Trials for Off Label Use of Botulinum Toxins

         NCT: national clinical trial. a Denotes industry-sponsored or cosponsored trial.

References

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2. U.S. Food and Drug Administration (FDA) prescribing information for Jeuveau®. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&varApplNo=761085. Accessed June 19, 2020.
3. U.S. Food and Drug Administration (FDA) prescribing information for Botox®. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=103000. Accessed May 10, 2020.
4. Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol. 2013;108:1238-1249. doi:10.1038/ajg.2013.196.
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8. Pringsheim T, Okun MS, Müller-Vahl K, et al. Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology. 2019;92:896-906. doi:10.1212/WNL.0000000000007466.
9. U.S. Food and Drug Administration (FDA) prescribing information for Dysport®. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=125274. Accessed May 10, 2020.
10. U.S. Food and Drug Administration (FDA) prescribing information for Xeomin®. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=125360. Accessed May 10, 2020.
11. U.S. Food and Drug Administration (FDA) prescribing information for Myobloc®. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=103846. Accessed May 10, 2020.
12. Gronseth GS, Cox J, Gloss, D. et al. on behalf of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Clinical Practice Guideline Process Manual. 2017. American Academy of Neurology. Retrieved from: https://www.aan.com/siteassets/home-page/policy-and-guidelines/guidelines/about-guidelines/17guidelineprocman_pg.pdf. Accessed July 21, 2020.
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15. Lakraj A, Moghimi N, Jabbari B. Hyperhidrosis: Anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins. 2013;5:821-840. doi:10.3390/toxins5040821.
16. Gutschow CA, Töx U, Leers J, Schäfer H, Prenzel KL, Hölscher A. Botox, dilation, or myotomy? Clinical outcome of interventional and surgical therapies for achalasia. Langenbecks Arch Surg. 2010;395:1093-1099. doi:10.1007/s00423-010-0711-5.
17. Enestvedt BK, Williams JL, Sonnenberg A. Epidemiology and practice patterns of achalasia in a large multi-centre database. Aliment Pharmacol Ther. 2011;33:1209-1214. doi:1111/j.1365-2036.2011.04655.x.
18. Bellofatto M, De Michele G, Iovino A, Filla A, Santorelli F. Management of hereditary spastic paraplegia: A systemic review of the literature. Frontiers in Neurology. 2019;10(3). doi:10.3389/fneur.2019.00003.
19. Piccinni, G, Poli E, Angrisano A, Sciusco A, Testini M. Botox® for chronic anal fissure: Is it useful? A clinical experience with med-term follow-up. Acta Biomed. 2009;80:238-242.
20. Karp BI. Botulinum toxin physiology in focal hand and cranial dystonia. Toxins. 2012;4:1404-1414. doi: 3390/toxins4111404.
21. Lungu C, Karp BI, Alter K, Zolbrod R, Hallett M. Long term follow-up of botulinum toxin therapy for focal hand dystonia: Outcome at 10 or more years. Mov Disord. 2011;26(4):750-753. doi:10.1002/mds.23504.
22. Jackman M, Delrobaei M, Rahimi F, et al. Predicting improvement in writer’s cramp symptoms following botulinum neurotoxin injection therapy. Tremor and Other Hyperkinetic Movements. 2016;6. doi:10.7916/D82Z15Q5.
23. Barbeiro S, Atalaia-Martins C, Marco P, et al. Long-term outcomes of botulinum toxin in the treatment of chronic anal fissure: 5 years of follow up. UEG Journal. 2017;5(2):293-297. doi:10.1177/2050640616656708.
24. Bilyk JR, Yen MT, Bradley EA, Wladis EJ, Mawn L. Chemodenervation for the treatment of facial dystonia. Ophthalmology. 2018;125:1459-1467. doi:org/10.1016/j.ophtha.2018.03.013.
25. Hellman A, Torres-Russotto D. Botulinum toxin in the management of blepharospasm: Current evidence and recent developments. Therapeutic Advances in Neurological Disorders. 2015;8(2):82-91. doi:10.1177/1756285614557475.
26. Pandey S. A practical approach to management of focal hand dystonia. Ann Indian Acad Neurol. 2015;18(2):146-153. doi:10.4103/0972-2327.156563.
27. Persaud R, Garas G, Silva S, Stamatoglou C, Chatrath P, Patel K. An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions. J R Soc Med Sh Rep. 2013;4:10. doi:10.1177/2042533312472115.

Codes

Policy History