BlueCross BlueShield of Tennessee Medical Policy Manual

IncobotulinumtoxinA

NDC CODE(S)

00259-1605-XX Xeomin 50 UNIT SOLR (MERZ PHARMACEUTICAL)

 

00259-1610-XX Xeomin 100 UNIT SOLR (MERZ PHARMACEUTICAL)

 

00259-1620-XX Xeomin 200 UNIT SOLR (MERZ PHARMACEUTICAL)

DESCRIPTION

Botulinum toxin, produced by the bacterium Clostridium botulinum, is one of the most potent naturally occurring neurotoxins known.  It induces chemodenervation by first binding to acceptors on motor nerve terminals.  It then enters the terminals and blocks the release of acetylcholine and other neurotransmitters at the neuromuscular junction.  This renders smooth and striated muscles incapable of contraction.  Acetylcholine also mediates the sympathetic innervation of the sweat glands, explaining how botulinum toxin disrupts the cholinergic outflow to the skin and halts glandular secretion.

The minute amount of toxin used clinically produces only partial, localized chemical denervation with transient results.  Over time, axons generate temporary sprouts which release acetylcholine and the original nerve terminal is eventually re-established, ending the toxin’s therapeutic activity.

Seven antigenic-specific serotypes of botulinum toxin have been identified, types A, B, C-1, D, E, F and G, but only botulinum toxin types A and B are commercially available.  These commercial preparations of the two serotypes (three of serotype A and one of serotype B) vary widely in potency and dosage.  They have been given different names to reinforce these differences and to prevent medication errors.  It is emphasized that the use and dosage of different formulations of botulinum toxin is not interchangeable.

This policy applies only to incobotulinumtoxinA marketed as Xeomin®.

POLICY

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

RENEWAL CRITERIA

INDICATION(S) DOSAGE & ADMINISTRATION
Cervical Dystonia 120 units divided among the affected muscles every 12 weeks or longer, as necessary
Blepharospasm 1.25 - 5.6 units per injection site, not to exceed 35 units per eye, every 12 weeks or longer, as necessary
Upper limb spasticity Up to 400 units total no sooner than every 12 weeks
Chronic Migraine Up to 200 units divided among the affected muscles every 12 weeks
Severe primary axillary hyperhidrosis 50 Units intradermally per axilla every 16 weeks
Neurogenic bladder /Detrusor overactivity Up to 200 units per treatment divided among the affected muscles every 12 weeks.
Overactive Bladder (OAB) Up to 100 units per treatment divided among the affected muscles every 12 weeks

LENGTH OF AUTHORIZATION

Coverage will be provided for six months and may be renewed

Click here to view DOSAGE LIMITS

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.

IMPORTANT REMINDER

We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION 

For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).

No controlled studies were found in the published literature that validate the use of incobotulinumtoxinA for the treatment or prevention of other conditions or diseases.

SOURCES

BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2017). Botulinum toxin (5.01.05). Retrieved January 8, 2018 from BlueWeb.

BlueCross BlueShield Association. Medical Policy Reference Manual. (5:2017). Treatment of hyperhidrosis (8.01.19). Retrieved January 8, 2018 from BlueWeb.

Lexi-Comp Online. (2018). AHFS DI. IncobotulinumtoxinA. Retrieved January 8, 2018 from Lexi-Comp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Drug Evaluations. (2017, November). IncobotulinumtoxinA. Retrieved January 8, 2018 from MICROMEDEX Healthcare Series.

U. S. Food and Drug Administration. (2015, December). Center for Drug Evaluation and Research. Xeomin®(incobotulinumtoxinA). Retrieved January 8, 2018 from http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/125360s067lbl.pdf.

ORIGINAL EFFECTIVE DATE:  12/1998

MOST RECENT REVIEW DATE:  3/13/2018

ID_MRx

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.

 

 

DOSAGE LIMITS

Maximum billable units per dose and over time by indication as a Medical Benefit; 1 billable unit = 1 unit

Indication

Billable Units

Per # days

Cervical Dystonia

200

84

Blepharospasms

100

84

Upper Limb Spasticity

400

84

Chronic Migraine prophylaxis

200

84

Incontinence due to neurogenic detrusor overactivity

200

84

Overactive Bladder (OAB)

100

84

Severe primary axillary hyperhidrosis

100

112