Botulinum toxin

Coverage decision

Botulinum toxin products require prior authorization. Authorization criteria and coverage limitations depend on the condition being treated. You can request authorization by completing and submitting the prior authorization form for chronic migraine or for non-migraine indications.

OnabotulinumtoxinA for prevention of chronic migraine (up to five treatment courses)

Coverage criteria

Initial treatment course (all of the following conditions must be met):

  1. Patient meets the International Headache Society’s diagnostic criteria for chronic migraine (headache on at least 15 days per month for more than three months, which has the features of migraine headache on at least 8 days per month).
  2. Patient has kept a daily headache diary for at least three months to confirm diagnosis and establish baseline.
  3. Chronic migraine diagnosis is causally related to an accepted industrial injury or occupational disease.
  4. Patient has tried and failed at least three prophylaxis drugs from at least two different drug classes.
  5. Migraine condition is being appropriately managed to avoid medication overuse (rebound) headaches.
  6. Patient is at least 18 years old.

Additional treatment courses (all of the following conditions must be met):

  1. Patient’s daily headache diary demonstrates a greater than 50% reduction in headache frequency after two treatment cycles.
  2. Patient has not already met the five-treatment course limit.
Background information

The state’s Health Technology Clinical Committee (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).” Complete information is available at: http://www.hca.wa.gov/about-hca/health-technology-assessment/health-technology-reviews.

Effective date of initial coverage decision is 12/1/17. Decision was revised on 10/1/18, which is retroactive to 12/1/17.

Regulatory authority and related information

RCW 51.08.100
RCW 51.08.140
RCW 70.14.080 through 70.14.130
Health Technology Assessment Program


Botulinum toxin for non-migraine indications (up to two treatment courses, except for catastrophic injuries*)

Coverage criteria

Initial treatment course (all of the following conditions must be met):

  1. Condition being treated is causally related to the industrial injury or occupational disease.
  2. 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).
  3. Patient has tried and failed conservative treatment, such as oral medication and physical therapy.
  4. 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):

  1. Patient did not experience a severe adverse outcome from a previous botulinum toxin treatment course.
  2. Previous treatment course resulted in the patient being able to engage in vocational rehabilitation or return to work.
  3. 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.