Botox, a popular non-surgical treatment for cosmetic problems and certain muscle conditions (spasms, contractions, stiffness) has been in use since 1978. From removing wrinkles to helping resolve chronic migraines, there are a lot of uses for Botox, but it is most commonly used to treat cosmetic concerns that occur naturally with aging.
The many U.S. medical insurance carriers each have unique qualifications and approval policies for covering Botox when used for non-cosmetic medical purposes, but all of them agree that Botox administered for the sole purpose of improving cosmetic appearances is not covered.
Botox is covered by most medical insurance providers when the product is used in an FDA-approved manner (not “off-label”) in order to treat a qualifying medical condition in a qualifying patient, according to prepublished insurance company policies. Uses that aren’t covered by insurance include all use for solely or primarily cosmetic purposes, any off-label use that hasn’t specifically been approved by the FDA after trials have been conducted on that exact use, and any use in a patient who is pregnant, has certain preexisting health conditions, or is allergic to any of the ingredients used in Botox and similar neuromodulators.
Insurance providers may also require that certain medications are tried before Botox or its many so-called “alternatives” are used.
Patients who suffer from a long-term medical condition that Botox may help correct are the most likely to benefit from trying to get approved for insurance coverage for their use of the product.
Medical treatments covered by insurance
Botox may be covered by one’s health insurance provider if they can demonstrate that it is medically necessary.
In light of this, it is necessary to adhere to a stringent approach given that the vast majority of medical treatments are performed more for aesthetic purposes than for medicinal ones. The following are some examples of conditions that an insurance policy could cover the costs of, depending on the condition and specifics of one’s policy.
These may take chronic form and keep getting worse if you don’t get your migraines treated. This means that Botox actually may be covered since it is a medical issue that you are experiencing.
Severe Neck Spasms
The muscles in your neck and back area are known to keep twitching involuntarily with spasms. These spasms may occur in the neck, arms, eyes, or legs area. Unfortunately this condition can affect you medically and during your daily life for example while you’re driving or at work. This condition may be covered by some insurance companies if your health and safety is at risk.
This condition may cause a sudden urge to urinate quite often, leading to incontinence. Bladder incontinence is a serious condition that many people suffer from and for this reason it may be covered by your insurance.
When you have cross eyes, you may feel trouble focusing which can lead to eye soreness or pain. Again, since this is causing pain and can affect your daily life, some insurance companies may cover it.
Temporomandibular Joint Disorder
This issue is a special disorder condition that can result in jaw pain due to clicking or locking. You may find that you are having trouble eating or chewing because of it. If this is affecting your health, it could be covered by insurance.
There is a chance that your body may produce sweat abnormally. You may experience excessive perspiration, which can lead to an overall unhealthy well-being. If your doctor determines that you experience this condition, it may be covered by your insurance plan.
Some companies provide coverage only when it is not related to cosmetic reasons, like the ones mentioned above. Nevertheless, it is important to consult the insurance company beforehand to clarify whether they cover specific Botox treatments or not.
Getting your medical insurance provider to cover the cost of Botox injections will involve your licensed injector submitting the necessary requirements. Like many providers, BlueCross BlueShield, for instance, will not cover the use of Botox and similar neuromodulators in a patient who is pregnant or nursing, but will do so if their medical needs fit into one of the predetermined conditions for which coverage is provided.
Many of these conditions are noted above and more of them can be found in this policy. Your medical insurance provider very likely has a pre-existing policy of their own.
Like other providers, BlueCross BlueShield also requires that the uses to which Botox is being put are FDA-approved uses, and many of the current uses of Botox are, unfortunately, not FDA-approved uses but are considered “off-label.” A licensed physician may use Botox (and other medications) in an off-label manner if they have reason to believe it will help and not harm a patient, or that its potential rewards outweigh its potential risks.
“From the FDA perspective, once the FDA approves a drug, healthcare providers generally may prescribe the drug for an unapproved use when they judge that it is medically appropriate for their patient.”U.S. FDA, Feb 5, 2018 “Understanding Unapproved Use of Approved Drugs ‘Off Label’”
How to determine if Botox is covered by insurance
Some companies may cover all or some of the costs for your Botox treatment. This depends on the company’s policies. They may need to verify some things about you, like the total number of treatments you got, medical reports, etc. It’s important to work with the insurance company to determine what costs are covered and which are not.
What are your options if you’re not covered by insurance?
Even if your insurance does not pay for Botox injections, you are able to continue receiving them. However, you will be responsible for paying the whole amount of the fees out of your own pocket.
The total cost of your Botox treatment will be determined by the number of treatment sessions you need as well as the quantity of the medicine that must be administered during each session.
If you consult with an expert, they should be able to break down the total cost of your Botox treatment for you and provide you with the information you need to move forward with your treatment.
If you work with them closely, they should also be able to provide you with the information you need to determine if it is covered by insurance in the first place. To put it simply, Botox treatments for aesthetic purposes are not going to be covered by insurance, but if you are receiving the treatment because of a medical condition, there is a possibility that your insurance will pay for it.