Coverage of Conditions and Treatments (Coverage Decisions)
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
See Treatment Guidelines and Resources for additional information.
Botulinum toxin products require prior authorization. Authorization criteria and coverage limitations depend on the condition being treated. For migraine headaches, coverage criteria are a combined product of the state’s Health Technology Clinical Committee (HTCC) and L&I. You can request authorization by completing and submitting the prior authorization form for chronic migraine or for non-migraine indications. Note that botulinum toxin products are covered only for FDA-approved uses, with the exception of botulinumtoxinA formulations for cervicobrachial syndrome.
OnabotulinumtoxinA for prevention of chronic migraine (up to five courses).
Additional L&I criteria:
- Chronic migraine diagnosis is causally related to an accepted industrial injury or occupational disease.
- Patient has kept a daily headache diary for at least three months to confirm diagnosis and establish baseline headache frequency.
- Patient is at least 18 years old.
HTCC reviewed the treatment of chronic migraine and chronic tension-type headache in May 2017 and finalized the coverage determination on July 14, 2017. HTCC then revised the determination on July 13, 2018 to remove the following requirement for discontinuation, “Has changed to episodic migraine (defined as < 15 headache days per month).”
Effective date of initial coverage decision is 12/1/17. Decision was revised on 10/1/18, which is retroactive to 12/1/17.
Botulinum toxin for non-migraine indications (up to two courses, except for catastrophic injuries*)
Initial treatment course (all of the following conditions must be met):
- Condition being treated is causally related to the industrial injury or occupational disease.
- Condition being treated is an FDA-approved indication for the requested botulinum toxin product, with the exception of cervicobrachial syndrome, for which a botulinumtoxinA formulation (abobotulinumtoxinA – Dysport®, incobotulinumtoxinA – Xeomin®, or OnabotulinumtoxinA – Botox®) may be covered (see Appendix A of Neurogenic Thoracic Outlet Syndrome Treatment Guideline).
- Patient has tried and failed conservative treatment, such as oral medication and physical therapy.
- Botulinum toxin injections are part of an agreed upon treatment plan with clearly stated treatment goals of completing vocational rehabilitation and/or returning to work.
Additional treatment courses (all of the following conditions must be met):
- Patient did not experience a severe adverse outcome from a previous botulinum toxin treatment course.
- Previous treatment course resulted in the patient being able to engage in vocational rehabilitation or return to work.
- Patient has not already met the two-treatment course limit.
*Patients with catastrophic injuries, such as spinal cord injury in which significant recovery of physical function is not expected, are exempt from the two-course limit and the requirement of meaningful improvement in function. A maximum of four courses of injections may be authorized per year, with prior authorization.