Medical Policy Updates

Notification of Policy Revisions Effective November 05, 2007 (Posted August 27, 2007)

Medical Policy	Revision
Botulinum Toxin Injection	Under "When Covered" section: 1.c.- added "such as hemifacial spasm"; 1.d.- added "(see "Policy Guidelines" section for use of Botulinum Toxin for this indication)"; 2.i.- added "or to demyelinating conditions such as multiple sclerosis."; deleted 2.k. Spasmodic torticollis; 3.b.- revised to "lower esophageal achalasia where the patient has not responded to dilation therapy or where the patient is considered a poor surgical candidate." Under "When not Covered" section: 3.a.- end of sentence revised to "and cervicogenic or "cervicodystonic"; added 3.l. priformis syndrome. Under "Policy Guidelines" section: Added A.1-5: Use of Botulinum Toxin for Cervical Dystonia (Spasmodic Torticollis): ALL of the following criteria must be met: 1) Postural disturbance and pain must be of moderate or greater severity as documented by interference with specific activities of daily living and unresponsive to a trial of appropriate standard conservative therapy that may include non-narcotic analgesics, muscle relaxants and physical modalities; AND 2) There are clonic and/or tonic involuntary contractions of multiple neck muscles (that is, sternocleidomastoid, splenius, trapezius and/or posterior cervical muscles); AND 3) There is sustained head torsion and/ or tilt with limited range of motion in the neck; AND 4) The duration of the condition must be greater than six months; AND 5) Alternative causes of the patient's symptoms have been considered and ruled out including chronic neuroleptic treatment, cervicogenic headaches, myofascial pain syndrome, contractures or other neuromuscular conditions. Added B. Contraindications for use of Botulinum toxin: 1)Absolute: a. Inflammation or infection at the site of injection. b. Allergy to the drug. 2) Relative: a. Inability of patient to cooperate b. Coagulopathy c. Disease of neuromuscular transmission: i. Myasthenia Gravis ii. Eaton Lambert Syndrome iii. Amyotrophic lateral sclerosis iv. Peripheral neuropathy v.Motor neuron disease d. Concurrent use of medications that affect neuromuscular transmission such as aminoglycoside antibiotics. Medical Term Definitions added. Notification given 8/27/07. Effective date 11/5/07.

Medical Policy

Revision

Botulinum Toxin Injection

Under "When Covered" section: 1.c.- added "such as hemifacial spasm"; 1.d.- added "(see "Policy Guidelines" section for use of Botulinum Toxin for this indication)"; 2.i.- added "or to demyelinating conditions such as multiple sclerosis."; deleted 2.k. Spasmodic torticollis; 3.b.- revised to "lower esophageal achalasia where the patient has not responded to dilation therapy or where the patient is considered a poor surgical candidate." Under "When not Covered" section: 3.a.- end of sentence revised to "and cervicogenic or "cervicodystonic"; added 3.l. priformis syndrome. Under "Policy Guidelines" section: Added A.1-5: Use of Botulinum Toxin for Cervical Dystonia (Spasmodic Torticollis): ALL of the following criteria must be met: 1) Postural disturbance and pain must be of moderate or greater severity as documented by interference with specific activities of daily living and unresponsive to a trial of appropriate standard conservative therapy that may include non-narcotic analgesics, muscle relaxants and physical modalities; AND 2) There are clonic and/or tonic involuntary contractions of multiple neck muscles (that is, sternocleidomastoid, splenius, trapezius and/or posterior cervical muscles); AND 3) There is sustained head torsion and/ or tilt with limited range of motion in the neck; AND 4) The duration of the condition must be greater than six months; AND 5) Alternative causes of the patient's symptoms have been considered and ruled out including chronic neuroleptic treatment, cervicogenic headaches, myofascial pain syndrome, contractures or other neuromuscular conditions. Added B. Contraindications for use of Botulinum toxin: 1)Absolute: a. Inflammation or infection at the site of injection. b. Allergy to the drug. 2) Relative: a. Inability of patient to cooperate b. Coagulopathy c. Disease of neuromuscular transmission: i. Myasthenia Gravis ii. Eaton Lambert Syndrome iii. Amyotrophic lateral sclerosis iv. Peripheral neuropathy v.Motor neuron disease d. Concurrent use of medications that affect neuromuscular transmission such as aminoglycoside antibiotics. Medical Term Definitions added. Notification given 8/27/07. Effective date 11/5/07.