Does Medicare Cover Botox?

Botox first became a household name for its ability to turn back the clock on facial aging. However, if you are considering Botox for cosmetic reasons and expecting Medicare coverage, you’ll be disappointed. Medicare only covers Botox if your doctor considers it to be medically necessary treatment for a health condition.

Medicare does not cover cosmetic treatments like Botox,” says Susan Stewart, a licensed Medicare insurance broker in Muskegon, Michigan and advisor to the Senior Citizens League. “It will only consider coverage for procedures deemed medically necessary, provided the (Food and Drug Administration) has approved Botox for the specific condition.”

What Is Botox?

Botox (onabotulinumtoxinA) is derived from botulinum toxin, produced by the bacterium Clostridium botulinum. In controlled doses, this toxin has become widely used to treat both medical and cosmetic purposes due to hyperactive muscles.

Botox temporarily weakens or paralyzes muscles by blocking the release of acetylcholine, a neurotransmitter necessary for muscle contraction. The effects of Botox typically last three to 12 months, depending on the treatment and individual factors.

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“It is believed that Botox alters internal pain signaling pathways and desensitizes sensory nerves near the injection sites,” says Dr. Hida Nierenburg, the program director for headache fellowship and the associate program director for the neurology residency program at Nuvance Health in Poughkeepsie, New York.

What Medical Conditions Are Treated by Botox?

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While Medicare does not cover Botox for cosmetic use, it does cover it for certain conditions linked to muscle and nerve issues.

Botox has been approved by the FDA to treat several conditions, including:

Cervical dystonia. Cervical dystonia is a condition characterized by involuntary spasms that lead to abnormal head positioning and neck pain. Botox blocks the signals in the muscles of the affected area to reduce contractions.

Chronic migraine. Chronic migraines are defined as 15 or more migraines lasting four or more hours per month. As a neurotoxin, Botox temporarily paralyzes muscles in the head and face and deactivates pain receptors in the muscles’ nerves.

Excessive sweating. Botox stops the body from overproducing sweat by blocking the nerve signals in the sweat glands.

Overactive bladder. An overactive bladder causes a frequent and urgent need to urinate and can lead to incontinence. Botox prevents the bladder wall muscles from squeezing to help reduce the need for frequent urination.

Severe muscle spasticity. Severe muscle spasticity is involuntary and sometimes painful twitching of the muscles. These contractions can affect movement and range of motion, which can significantly impact daily life. Botox works by blocking neurotransmitters that cause muscles to contract and tighten and provides relief from pain and muscle stiffness.

Temporomandibular joint disorder (TMJ). TMJ is a condition that causes your jaw to click or lock. It can lead to jaw pain and trouble eating and drinking. When Botox is injected into the jaw muscles it helps paralyze the joint and blocks nerve signals that cause contractions.

These procedures are typically performed as an outpatient procedure.

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What Does Medicare Cover?

When the FDA has approved Botox for a specific medical condition, Medicare generally covers the cost.

If it is approved after a doctor deems it medically necessary, it is usually covered by Medicare Part B and Medicare Advantage plans.

“Since it involves a procedure rather than simply a drug, it is typically covered under Part B. With a Medigap plan and prior approval, the procedure would likely be covered at 100%. With a Medicare Advantage plan, there would likely be a 20% copay and consideration of being in network advised,” Stewart says.

Coverage Requirements

Before getting approval for Botox injections, the following needs to be met:

Documentation of medical necessity. Your doctor must document that Botox is medically necessary. Many times, they need to provide documentation that other treatments have been tried and were unsuccessful.

FDA approval. The use of Botox must be approved by the FDA for the specific condition being treated.

Prior authorization. In most cases, Medicare Part B or your Medicare Advantage plan requires prior authorization before the procedure can be performed.

Botox Cost

The cost of Botox treatment covered under Medicare is not fixed and can vary based on several factors, including:

— Dose

— Geographic location

— Medical condition

— Medicare Advantage plan

— Number of injections

— Size of the treatment area

There may be other costs that affect the price, including outpatient center fees or auxiliary prescriptions (such as numbing cream or pain killers).

Check with your doctor or specific plan to determine your costs ahead of time. To potentially bring down the price, you can sign up for a savings card from its manufacturer or call them directly at 800-44-BOTOX.

Preparing for Botox Injections

There are a few steps related to coverage that should be completed before going to the doctor’s office for Botox injections. These include:

Understand the costs. Ask for a breakdown of costs, including the price per unit of Botox and any additional fees.

Obtain prior authorization. Your doctor will need to submit for a prior authorization before the procedure is approved in most Medicare Advantage plans.

Verify your coverage. Double check with Medicare or Medicare Advantage plan if there are any specific requirements that need to be met.

“It can be a lengthy process that requires thorough diligence on the part of the beneficiary as well as the medical provider,” Stewart says.

Bottom Line

While Medicare does not cover Botox for cosmetic reasons, the treatment is covered for other FDA-approved indications, such as chronic migraines, excessive sweating and an overactive bladder.

Once it’s been determined by your doctor as medically necessary, you will need to work with your doctor to obtain prior authorization before scheduling the appointment. Botox shots are considered a procedure and are therefore covered under Medicare Part B as well as through Medicare Advantage plans.

Check with your plan to determine coverage requirements and associated costs. By ensuring that the treatment is medically necessary and meets Medicare’s guidelines, you can increase the likelihood of having Botox injections covered by Medicare.

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