CareCost Prior authorization
Required
Check what the payer requires before you schedule Botox.
Prior authorization · clinical prerequisites · quantity limits · reauthorization
29 payer policy sets carry a botulinum toxin coverage policy · source-linked · reviewed September 2026
Aetna + chronic migraine is shown as a live example until you choose a payer.
This payer requires an approval on file before Botox is purchased or administered for this member.
Precertification of botulinum toxin (Botox [onabotulinumtoxinA]; Daxxify [daxibotulinumtoxinA-lanm], Dysport [abobotulinumtoxinA]; Myobloc [rimabotulinumtoxinB]; and Xeomin [incobotulinumtoxinA]) is required of all Aetna participating providers and members in applicable plan designs.
Covered under ICD-10 G43.701, G43.711, G43.909, R51.9.
Chronic Migraine: Recommended total dose 155 Units, as 0.1 mL (5 Units) injections per each site divided across 7 head/neck muscles
What opens in CareCost
Aetna · Botox · Chronic migraine
For every requirement: the exact payer criteria, the source citation, a check-off, and a save to the patient’s chart.
In CareCost: check off each requirement · save to the patient · print for the chart
Aetna · Botox · Chronic migraine
You have already checked the policy, indication and covered dose. Open the remaining requirements and work them as a patient checklist.
CareCost tracks Botox coverage requirements across 29 payer policy sets.
Aetna · Anthem / Elevance · Cigna · UnitedHealthcare · Regence · Premera · BCBS plans + more
Coverage clearance is only the first step.
CareCost carries the same patient through the entire workflow.
Finish this patient’s estimate →22 of 29 commercial payers with an onabotulinumtoxinA policy require prior authorization. Clinical prerequisite, quantity-limit and reauthorization rules vary by indication and by plan; 771 rules apply across the 29 payers CareCost has read.
22 require PA · 24 require a documented clinical prerequisite · 4 restrict site of care · 76 rules set quantity limits
22 of the 29 onabotulinumtoxinA policies CareCost has read require an approval on file before Botox is purchased or administered.
Coverage depends on the indication in the payer’s onabotulinumtoxinA policy and the ICD-10 code billed — chronic migraine, cervical dystonia, overactive bladder, neurogenic detrusor overactivity, limb spasticity, axillary hyperhidrosis, blepharospasm or strabismus.
24 of 29 payers require another product or step first, and the step is indication-specific — an anticholinergic for overactive bladder and neurogenic detrusor overactivity, two prophylactic medication classes for chronic migraine, a topical agent for axillary hyperhidrosis.
76 rules set a Units-per-interval ceiling. The label itself caps adults at 400 Units in any 3-month interval (pediatric patients at the lesser of 10 Units/kg or 340 Units), and most payer policies write that ceiling directly into the coverage criteria.
31 rules ask for documented response rather than a renewal date, before a payer approves another treatment session.
4 payers CareCost has read restrict where the injection can be administered.
Five botulinum toxin products cover at least one Botox indication: Botox itself (J0585, AbbVie/Allergan), Dysport (J0586, Ipsen), Xeomin (J0588, Merz), Myobloc (J0587, Supernus) and Daxxify (J0589, Revance). Each is a distinct molecule at a distinct potency — a Botox Unit, a Dysport Unit and a Xeomin Unit are not interchangeable, and no payer policy CareCost has read converts between them. 24 of the 29 onabotulinumtoxinA policies CareCost has read require another product or step before Botox is covered, and for Botox that step is almost always an oral or topical prerequisite rather than a rival toxin.
| Payer | Indication | Prerequisite, quoted from the policy |
|---|---|---|
| Aetna Commercial |
Chronic migraine | “Member completed an adequate trial of (or has a contraindication to) two migraine preventative therapies coming from at least 2 of the following classes” |
| Florida Blue Commercial |
Chronic migraine | “Member has had an inadequate response to at least 6 weeks of continuous treatment, at a generally accepted dose, with a CGRP receptor antagonists FDA- approved for migraine prophylaxis” |
| BCBS Mississippi Commercial |
Overactive bladder / neurogenic detrusor overactivity | “Individual has failed (see Policy Guidelines section) or is intolerant to an anticholinergic agent (e.g. oxybutynin, tolterodine, trospium, darifenacin, solifenacin or fesoterodine) AND Myrbetriq (mirabegron)” |
| Anthem / Elevance Commercial |
Axillary hyperhidrosis | “Individual has failed a 6 month trial of any one or more types of non-surgical treatment” |
There is no national coverage determination for botulinum toxins. Coverage runs through your MAC’s botulinum toxin LCD — the governing local coverage determinations are published in the CMS Medicare Coverage Database, and a MAC can differ from its neighbour on the same drug.
This is the Original Medicare answer. A Medicare Advantage plan administers the same Part B benefit but can layer its own prior-authorization rules on top — check the plan’s own policy rather than assuming the Original Medicare rules below carry over.
The diagnosis selector above keys on the same indication codes shown in the table — the Clearance corpus stores each payer’s rules against the indication, not the ICD-10 code by itself, so picking “Chronic migraine” or “Axillary hyperhidrosis” is what routes the scan to the right rules. Pick the payer and the indication, and the scan reads back that payer’s prior-authorization, clinical-prerequisite, quantity-limit and reauthorization rules for it.
MUE J0585 is 800 Units per day, on both the practitioner and facility claim-edit tables. A single high-dose spasticity session that sums two indications in one visit can approach that ceiling faster than the drug quantity alone suggests. Guidance codes 95873 (electrical stimulation) and 95874 (needle EMG) are only billable as an add-on to the extremity, trunk, neck and laryngeal codes, never alongside 64615, 64612, 67345, 64650/64653 or 52287. 96372 is not a valid administration code for Botox on any claim, Medicare or commercial; the CPT follows the site treated.
Payer citation language above is drawn from CareCost’s own onabotulinumtoxinA policy corpus (29 payers). Check the specific payer’s language →
Chronic migraine is a covered indication under 27 of the 29 onabotulinumtoxinA policies CareCost has read, but coverage usually depends on a prerequisite. Aetna requires an adequate trial of, or a contraindication to, two migraine preventative therapies from at least two drug classes; Florida Blue requires an inadequate response to at least six weeks of a CGRP receptor antagonist. 24 of 29 payers require another product or step first. Check this patient’s payer →
22 of the 29 payers CareCost has read require prior authorization before Botox is covered. The packet generally needs the indication, the ICD-10 code, and documentation of the clinical prerequisite for that indication — for chronic migraine, Aetna’s language is “an adequate trial of (or has a contraindication to) two migraine preventative therapies coming from at least 2 of the following classes.” CareCost turns the applicable payer policy into a patient-level checklist. Open patient clearance →
31 rules in the corpus cover reauthorization, and most ask for documented response rather than a fixed calendar. Centene renews chronic migraine coverage when the member “has experienced and maintained a 30% reduction in monthly migraine headache frequency from baseline” after two treatment sessions; BCBS Kansas continues treatment beyond six months only if “migraine headache frequency reduced by at least 7 days per month.” No indication is retreated sooner than 12 weeks.
There is no national coverage determination for botulinum toxins, including Botox (J0585). Coverage runs through your MAC’s botulinum toxin LCD, and a Medicare Advantage plan can layer its own prior-authorization rules on top of the Part B benefit. See Original Medicare details ↓
Overactive bladder is a covered indication in 24 of 29 onabotulinumtoxinA policies CareCost has read, but coverage requires a documented step first. Aetna requires that the member has tried and failed behavioral therapy, and has had an inadequate response or intolerance to two agents from the anticholinergic or beta-3 adrenergic agonist classes; BCBS Mississippi requires failure of, or intolerance to, an anticholinergic agent AND Myrbetriq (mirabegron). A denial usually traces back to one of those steps missing from the chart. Check this patient’s payer →
Axillary hyperhidrosis is a covered indication under 22 of 29 policies CareCost has read, after topical treatment has failed. Anthem requires “a 6 month trial of any one or more types of non-surgical treatment,” and Florida Blue’s policy is stricter: “Condition is refractory to at least 2 months of continuous treatment with a topical agent (e.g., ≥10% aluminum chloride) unless use results in severe dermatitis.” Check this patient’s payer →
Data current: payer policies Aug 2026 · reviewed dates come from each payer
Payer medical and specialty-drug policies · prior-authorization criteria · clinical prerequisite and quantity-limit criteria · reauthorization criteria. Medicare coverage from the CMS Medicare Coverage Database. Every CareCost requirement links back to its source policy.