BotulinumToxinsCertificateofMedicalNecessity



|Certificate of Medical Necessity |[pic] |

Botulinum Toxins

|Fax this completed Certificate of Medical Necessity form along with other required | |Statewide Fax Number: 1-904-905-9849 |

|documentation including the history and physical, recent office notes (to include | | |

|patient’s symptoms and previously attempted conservative treatments, physical | | |

|examination): | | |

|Section A |

Physician Information

|Name:       |BCBSF Number:       |National Provider Identifier (NPI):       |

|Street Address:       |

|City:       |County:       |State:       |ZIP:       |

|Telephone Number:       |Fax Number:       |

|Contact Name:       |

Facility Information

|Name:       |BCBSF Number:       |National Provider Identifier (NPI):       |

|Street Address:       |

|City:       |County:       |State:       |ZIP:       |

|Telephone Number:       |Fax Number:       |

|Contact Name:       |

Member Information

|Last Name:       |First Name:       |

|Member/Contract Number (alpha and numeric):       |Date of Birth:       |

|Section B |

|Procedure Code (HCPCS):       |Medication Name:       |

|ICD-9 Code:       |Diagnosis Description:       |

|This medication is: administered by the Provider. self-administered by the patient. |

| Yes No N/A Is patient picking up medication at a retail pharmacy? |

| Yes No N/A Is provider buying the medication and billing BCBSF directly? |

| Yes No N/A Is provider obtaining medication from Caremark for drug replacement? |

|This is: an initial request. a continuation of therapy. |

| |

|If continuation, what date was therapy initiated?       / Current Daily Dosage:       |

| |

|If restart, what dates was therapy previously used?       / Why was therapy stopped and restarted?       |

|Prescribed Dosage:       |Dosing Frequency:       |Dosing administration route:       |

|Section C |

Check the box and complete the questions applicable to the patient’s condition:

| Strabismus or blepharospasm |

|Yes No |

|Associated with dystonia, including benign essential blepharospasm or VII nerve disorders in patients 12 years of age and older |

| |

| Cervical dystonia (spasmodic torticollis) of moderate or greater severity |

|Yes No |

|Must be associated with sustained head tilt OR |

| |

|Yes No |

|Abnormal posturing with limited range of motion in the neck AND |

| |

|Yes No |

|A history of recurrent involuntary contraction of one or more of the muscles of the neck (e.g., sternocleidomastoid, splenius, trapezius, or posterior cervical|

|muscles) |

| |

| Severe primary axillary hyperhidrosis |

|Yes No |

|Inadequately managed with topical agents AND |

| |

|Yes No |

|Is unresponsive or unable to tolerate pharmacotherapy prescribed for excessive sweating (e.g., anticholinergics, beta-blockers, or benzodiazepines) if sweating|

|is episodic AND |

| |

|Yes No |

|Patient has medical complications such as skin maceration with secondary infections or significant functional impairments |

| |

| Focal upper limb dystonia (e.g., 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 |

|Cerebral palsy |

|Spasticity related to stroke |

|Acquired spinal cord or brain injury |

|Hereditary spastic paraparesis |

|Spastic hemiplegia |

|Neuromyelitis optica |

|Multiple sclerosis or Schilder’s disease |

|Yes No |

|Resulting in functional impairment (interference with joint function, mobility, communication, nutritional intake) OR |

| |

|Yes No |

|Pain exists as a result |

| |

| Esophageal achalasia |

|Yes No |

|Must have tried and not responded to dilation therapy OR |

| |

|Yes No |

|Considered poor surgical candidate |

| |

| Sialorrhea (drooling) |

|Yes No |

|Associated with Parkinson disease OR |

| |

|Yes No |

|Associated with severe developmental delays when oral therapy fails (e.g., glycopyrrolate) OR |

| |

|Yes No |

|Associated with Cerebral Palsy when oral therapy fails (e.g., glycopyrrolate). |

| |

| Chronic anal fissure |

|Yes No |

|Must have failed conservative treatment (e.g., nitroglycerin ointment) |

| |

| Incontinence due to detrusor over reactivity (urge incontinence) |

|Yes No |

|Idiopathic OR |

| |

|Yes No |

|Due to neurogenic causes (e.g., spinal cord injury, multiple sclerosis) inadequately controlled with anticholinergic therapy |

| |

| Palmar hyperhidrosis |

|Yes No |

|Inadequately managed with topical agents AND |

| |

|Yes No |

|Inadequately managed with pharmacotherapy (e.g., anticholinergics, beta-blockers, or benzodiazepines, unless clinically contraindicated) AND |

| |

|Yes No |

|Patient has medical complications such as skin maceration with secondary infections or significant functional impairments |

| |

| Prevention of chronic migraine headaches (initial 6-month trial of |

|botulinum toxin for prevention of chronic migraine headaches) |

|Yes No |

|Adult individual diagnosed with chronic migraine headache AND |

| |

|Yes No |

|Fifteen (15) or more migraine days per month with headache lasting four (4) hours or longer AND |

| |

|Yes No |

|First episode at least six (6) months ago AND |

| |

|Yes No |

|Symptoms persist despite trials of at least 2 months (60 days) of at least 1 agent in a minimum of 2 of the following classes of medications used to prevent |

|migraines or reduce migraine frequency: |

|Antidepressants (e.g., amitriptyline, nortriptyline, doxepin) |

|Beta blockers (e.g., atenolol, metoprolol, nadolol, propanolol, timolol) |

|Angiotension-converting enzyme inhibitors/angiotensin II receptor blockers (e.g., lisinopril, candesartan) |

|Antiepileptics (e.g., valproate, topiramate, gabapentin) |

|Calcium channel blockers (e.g., diltiazem, nifedipine, nimodipine, verapamil). |

| |

| Prevention of chronic migraine headaches (continuing treatment with |

|botulinum toxin injection for ongoing prevention of chronic migraine headaches) |

|Yes No |

|Migraine headache frequency was reduced by at least 7 days per month (when compared to pre-treatment average) by the end of the initial trial OR |

| |

|Yes No |

|Migraine headache duration was reduced by at least 100 total hours per month (when compared to the pre-treatment average) by the end of the initial trial. |

| |

| Unlisted condition (please be sure to include supporting clinical notes for any unlisted conditions). |

Comments:

|      |

My signature below certifies that the information submitted on this form is accurate and these services are medically necessary.

|Ordering Physician’s Signature: |Date:       |

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