Medicare guidelines for Botox treatments include Botox injections to treat certain medical conditions. Further, the treatment must have FDA approval. Botox uses many forms a botulinum toxin to block specific nerves or paralyze confined muscle movement. Botox may serve many purposes, from cosmetics to medical. There’s more to know about this medication and the health conditions it treats. The best part is, if you meet the guidelines – Medicare may cover most of the costs.
Does Medicare Cover Botox?
The uses of Botox go beyond the skin, and Medicare coverage for Botox treatments are available for several medical conditions. If a doctor deems it medically necessary to treat you, Medicare likely covers the cost. Doctors use injections to treat excess sweating, leaky bladders, eye squints, and migraines. But, the primary use remains to reduce fine lines and facial wrinkles.
The FDA approves treatments for things like cervical dystonia, a nerve disease.
What Botox Treatments Does Medicare Cover?
- Chronic migraines
- Crooked eyes
- Extreme underarm sweating
- Eyelid muscle spasms
- Overactive bladders
- Upper limb spasms
How Much Does Botox Injections Cost?
Most health insurance plans cover medical Botox treatment under FDA approval. Usually, the dosage of 155 units costs around $300 to $600 for each treatment. Medicare’s injection cost may vary depending on plan coverage, medical condition, and the type of injection. Most plans have coverage for chronic migraines.
Contact your plan before getting any Botox injections. Ask your insurance provider if you need any paperwork for Medicare coverage to apply.
What are the Medicare Guidelines for Botox Injections?
You must try other treatments and see no improvement before coverage begins. Botox injections must be necessary to treat a health condition.
Is Cosmetic Botox Covered by Medicare?
Medicare guidelines for Botox injections don’t include cosmetic treatments. But, if cosmetic Botox is necessary due to an accident or injury – Medicare may apply.
Does Medicare Cover Botox for Migraines?
Yes, Medicare covers Botox for migraines, although it’s not intended for individuals who endure less than 15 days of headaches in a month. The FDA approves Botox for chronic migraines as an effective treatment. Headaches lasting 15+ days of the month are known as migraines.
Dr. Andrew Blumenfeld, Director, The Headache Center of Southern California, says:
“The more frequent the headaches, the better the patient does with Botox.”
Look for a neurologist or headache specialist that accepts your plan if you are considering Botox treatment.
Will Medicare Reimburse You For Botox Treatments?
Botox reimbursement from Medicare is rare; yet, you may have to file in some instances. For example, if you visit your doctors’ office under Medicare, your doctor may not bill Medicare. If this happens, you may be required to pay the cost. Though this may be a situation when filing a Medicare reimbursement claim is appropriate. However, this rarely happens. Most of the time, you receive a medical bill; it means your doctor isn’t accepting Medicare assignment.
FAQs
How to Get Medicare Coverage for Botox Treatments
Botox is an expensive service, and your Out Of Pocket cost may increase depending on the number of units you need to treat your condition. Medicare pays 80%, and the other 20% becomes an out of pocket cost. Because Botox is only a temporary fix - you may need treatment again in 4-6 months. Over time, that 20% can add up to a financial burden.
Supplement insurance picks up the remaining 20% for copayments, coinsurance, and deductibles. Medicare with a supplement plan is the best way to get help covering costs for procedures like Botox. Fill out our online rate form or give us a call today. One of our Medicare experts can help you to understand the plans and compare rates to save you the hassle.
Hi Lindsay. I’m trying to locate the guidelines for Migraines. I know it’s 15+ headaches but I can’t find the list of information that is needed. Could you point me to where this info is located? Thank you!
Hi Kara! I believe the guidelines you’re looking for are here.
Hi Lindsay,
I have always had Botox injections for my migraines on a 12-week schedule, or longer if no appointments are available. Now I’ve been scheduled for an appointment 11 weeks after my last appointment, since I would otherwise be seriously delayed (more than a month) in receiving my injections. Will Medicare cover this set of injections, since it’s a week earlier than normal?
Hi Lynn! As long as your doctor says it’s medically necessary, Medicare should cover the injections a week early.
Is the dx of essential tremor and dx of spasticity covered under Medicare. Thank you.
Hi Kim! Yes, if the doctor says Botox is medically necessary to treat your diagnosis then Medicare will cover it. You can read more information on the CMS website.
My wife has chronic migraines and was treated by a neurologist in Dallas. We live 300+ miles from Dallas and looked locally to see who might do the injections. A local Plastic Surgeon agreed to do this and has done it for others so my wife got injections of Botox in October of 2020. As my wife was to get another injection in March, 2021, we found out that Medicare only paid the doctor $100 and we don’t have a clue whether her Supplemental Part G paid anything. The doctor’s accountant said the bill was coded the same way the Dallas doctor coded his injections and our local doctor wrote off the unpaid sum and said he would no longer bill Medicare so we have to come up with approximately $1,700 per treatment. What should we do from here? We paid cash for the March 2021 cost.
Hi Jim! Did your previous doctor in Dallas submit any documentation to Medicare? Normally, you must try other treatments and see no improvement before coverage begins. I would reach out to the doctor in Dallas to find out if they submitted anything additional to Medicare to have the Botox covered. Since this is a different doctor, Medicare may require that doctor to also submit a treatment plan or proof of other treatments tried first. If you cannot get answers from your previous doctor, contact Medicare directly and ask why it was covered in Dallas but not by the local doctor. After Medicare paid their portion, they would’ve sent the balance to your Plan G carrier. If Medicare covered it then your Plan G would’ve picked up the balance with the exception of the Part B deductible if you haven’t met the deductible yet for the current calendar year. It sounds to me like Medicare only covered the office visit and denied covering the Botox for one reason or another. That’s why your Plan G didn’t pick up the balance because Medicare didn’t cover it first. I hope this helps!
I am receiving Botox for migraines. How many times per year does Medicare pay for the injections?
Hi Maureen! This depends on how often your doctor says the Botox injections are medically necessary.
My wife receives medical botox injections for the treatment of Blepharospasm. She went on Medicare as of 10/1/2020, and this is her first scheduled botox injection on Medicare. When she was covered by private health insurance, she arranged directly with a specialty pharmacy (Alliance Rx) to have the botox shipped to her opthalmologist. Our understanding is that medical botox injections are covered by Medicare Part B, but every time we call to inquire about how to get the botox shipped to the doctor, we’re referred to Part D. However, our Part D provider (United Healthcare) tells us (correctly, I believe) that medical botox is covered by Part B, not Part D. We just want to know who to contact to make arrangements for my wife’s medical botox prescription and have it sent to her othalmologist. Suggestions?
Hi George! Botox would be covered under Part B. I would have your doctor contact Medicare. Medicare will require documents from your doctor that shows Botox is medically necessary. Then your doctor would bill Medicare for the injections under Part B. You cannot bill Medicare yourself. I hope this helps!
Hi Lindsay – I’m the wife referred to by George Croner in a question he posted on 12/14/20. Here’s a bit of additional info for you. I’ve been receiving medically necessary botox injections from my physician since 2014, administered in her office and covered by private insurance. With a script to a specialty pharmacy, the botox was delivered directly to that physician’s office every time. In addition to the physician’s cost to perform the injection “procedure,” the botox itself was paid through the medical part of that private plan and not the drug plan. Seems intuitive to me since there is no procedure without the actual drug.
I became a Medicare participant as of 10/1/20 and have coverage under both Parts B and D. I still require these botox injections going forward. I do understand that the actual procedure performed by the doctor to inject the botox is covered under Part B of Medicare. The CPT code for this procedure is 64612. My question concerns the charge associated with the actual botox injectable drug. As has been true since 2014, the doctor’s office still sends the script to a specialty pharmacy, which then ships the vial containing the botox drug directly to the physician’s office where I receive the injection. I have now been on the phone for 2 days with medicare reps trying to make sure that I inform the specialty pharmacy correctly as to whether to process the charge for the botox drug itself through my Medicare Part B or Medicare Part D plan for coverage. No one can give me a definitive answer. I’ve been told that the drug
Onabotulinumtoxin A (Botox) is not listed on the Part D drug formulary. One Medicare rep told me that their records indicate that I pick up the drug myself and bring it to the physician’s office but that has never been true, and I don’t know if that mistaken assumption changes the equation at all. I’m stumped as to the answer regarding Part B or D, as are the Medicare advisors with whom I’ve spoken. Any guidance you can provide would be much appreciated. Thank you for your time. Gina Lagore
Hi Gina! Yes, this is a common question believe it or not! Your doctor would need to provide Medicare the right documentation to show that it’s medically necessary. Since your doctor is ordering the vial that is shipped directly to the doctors’ office and administering the injection in an outpatient setting, it should be billed under Part B. I hope this helps!
My wife gets severe migraines. WE have Medicare A and B plus Tricare for Life. TFL Pharmacy says it does not pay for Botox injections Does Medicare provide benifits for Botox treatments?
Hi Fred! Medicare Part B will cover Botox treatment if the doctor says it’s medically necessary.
I was diagnosed with cervical dystonia. I have tried numerous medications to control the neck spasms that go up into my head. These spasms make me very sick, and have brain fog, and migraines for weeks. My neurologist has suggested our next step would be botox injections. Does medicare cover these injections for cervical dystonia?
Hi Sandy. As long as your doctor finds it medically necessary to help treat your cervical dystonia, Medicare will cover the injections.
I have Medicare and a supplement plan, so I believe my Botox for my migraines should be covered at 80% by Medicare and the rest by my supplement plan. However my doctors office is telling me that I am responsible for the copay of the Botox medicine before it can be shipped to their office which was over $400.. Is this correct? Or should this be included in the part B plan that is paid by Medicare?
Hi Misty! Depending on which Medicare Supplement plan you have, the only out of pocket cost you MAY have to pay is the Part B deductible of $198. However, you never pay the Part B deductible at the doctor’s office. Always wait until Medicare bills you for it. If you have Plan F, then you have no deductible under Part B to pay at all, it’s covered by your Plan F. Either your provider’s office is misinforming you, or you don’t have a Medicare Supplement plan and may have a Medicare Advantage plan instead. Hopefully, this helps!
My husband has been receiving Botox for yrs(it works wonders for his migraines) then in July of this year we were told Medicare was requiring preauthorization for his injections it was a new process for some procedures they would require now and Botox was one of them it’s been 45 days and I’ve heard nothing from the doctors office I had to call them myself today and women was one leave and the other had left early for the day so i still couldn’t talk to anyone about my husband pre approval and it so frustrating because here a medication at actually was helping him that now is on hold because people are giving us the run around and he’s suffering because of it also!!
Hi Lisa! CMS did recently update prior authorization requirements for certain hospital outpatient department services, including Botox. Any Botulinum toxin injections will require prior authorization when provided on or after July 1st, 2020. If your husband’s primary care physician is not following through, I would contact Medicare directly to see if they can help.
Hello, In doing a Medicare compliance check, I keep seeing an alert stating botox is covered at a minimum of 16 weeks. Our physicians have always injected at 90 days (12 weeks). Does this mean we are not going to get paid? Please advise. Thank you.
Hi Janice! From my knowledge, according to Medicares guidelines, Botox shouldn’t be injected any more frequently than every 12 weeks. When you say the alert states “botox is covered at a minimum of 16 weeks,” that sounds to me like it’s stating Medicare will cover at minimum every 16 weeks, however, every 12 weeks is the maximum. Hopefully, that makes sense!
Is 155 units the max for botox for migraine headaches for Medicare pts.? Also, my doc does botox for stroke pt, etc and uses more botox. He has gone up to 400-500 before. what is the max dosage of botox on these situations. thanks
Hi Kim! The amount of units Medicare approves is dependent on the treatment plan. It’s important your doctor follows the correct coding guidelines and specific applicable code combinations prior to billing Medicare. Otherwise, the claim could be denied. I have not been able to find anything that specifies a limit on the number of units given for a specific treatment. As long as your doctor deems the injections medically necessary, they should be covered.
We just had a patient just tell us that beginning in September, Medicare will require authorization for Botox? Is this true? How would we go about getting authorization?
Hi Bobbie! Outside of some durable medical equipment, there is no prior authorization when it comes to Medicare claims. However, this is not the case with Medicare Advantage. If your patient has a Medicare Advantage plan, it’s the carrier requiring prior authorization, not Medicare. As of now, we have not heard anything about Medicare making changes where they require prior authorization for Botox. We will update this page accordingly if we do!
In regards to frequency of Botox – does it have to be every 84 days (12 weeks) or can one be seen sooner? Like every 80 days (10 weeks)? What are Medicare’s guidelines?
Hi Tami! As long as the doctors provide both diagnostics codes and services codes on the claim form, Medicare should approve the injections as often as your doctor finds them medically necessary.
It would be helpful if there was information about the frequency of Botox injections, how long in between treatments does Medicare allow.
Hi Tina! Botox injections fall under Part B. As long as the doctors provide both diagnostics codes and services codes on the claim form, Medicare should approve the injections as often as your doctor finds them medically necessary. You’ll have to pay the 20% coinsurance for each one. However, if you have a Medigap plan, the coinsurance will be covered. I hope this helps!