Botulinum Toxin (Botox/Dysport)

The TAC Medical Excess may apply to these services 

 

 

Policy

The TAC can fund the reasonable cost of botulinum toxin medication when required to treat a client's transport accident related injuries, and where the treatment is provided by a medical specialist trained in its use.

Transport Accident Act 1986 reference: s.3 'medical service' and s.60

Definitions

In this policy:

  • Botulinum Toxin is generally prescribed for focal spasticity and is mainly used following a neurological injury such as a spinal cord or traumatic brain injury. Botulinum toxin temporarily paralyses the injected muscles and prevents/reduces contractures, reducing the need for treatment such as surgery. It can also be used to increase function, eg. to make walking safer or to stop incontinence. Two common brands are Botox and Dysport.
  • Focal spasticity is a form of spasticity that affects a smaller part of the body, such as a hand or an extremity, and may also include areas such as the bladder (detrusor muscle) following traumatic brain injury or spinal cord injury. Generalised spasticity affects greater areas of the body.

Guidelines

What can the TAC fund?

The TAC can fund the reasonable cost of botulinum toxin ampoules when required to prevent or treat contractures due to focal spasticity within the first 18 months post-accident and where it is provided by the treating specialist. Where botulinum toxin is required for other indications, refer to 'When is prior written approval required?'

Who may request botulinum toxin treatment?

Botulinum toxin injections must be requested by a medical specialist trained in its use.

When is prior written approval required?

Prior written approval from the TAC must be obtained in the following situations:

  • where botulinum toxin injections for contracture control are to be given more than 18 months post-accident
  • where the indication for treatment is not contracture control/ prevention, ie. the injection is not urgent or within the first 18 months post-accident
  • for repeat injections (same muscle group) within an 8 week period in the first 18 months post-accident
  • where more than 400 units of Botox (4 units/kg or 200 units in children) or 1,000 units of Dysport is required within the first 18 months post-accident
  • where botulinum toxin is to be used to treat bladder instability.

What information does the TAC require to consider funding botulinum toxin when prior approval is necessary?

Information is needed from both the treating specialist and the treating physiotherapist collectively. For treatment of the hand, a hand therapist may be involved. The following information is required to evaluate clinical justification:

Treating Specialist

  • diagnosis and relation to transport accident injuries
  • results of urodynamics or gait analysis where applicable
  • name of muscle/s to be injected
  • effect of previous therapy interventions, eg. positioning, casting and orthoses
  • effect of previous botulinum toxin injections (noting muscles injected and dose)
  • dose of botulinum toxin required and frequency
  • expected future botulinum toxin injections
  • Medical Benefits Schedule (MBS) item number to be used

Physiotherapist/Hand Therapist

  • expected functional gains to be achieved
  • standardised objective outcome measures to be used to measure spasticity, eg. tardieu scores, and functional activity, eg. 10 metre walk speed, pre and post
  • intervention, ie. botulinum toxin plus therapy
  • request for post-injection management, eg. physiotherapy, casting and orthoses.

Will the TAC pay for needles separately?

The TAC will only consider payment for the stimulator needles required when the treatment is performed in the medical practitioner's private rooms.

How will the TAC fund injections provided by a public hospital?

Where treatment is administered to an in-patient in a public hospital, the Casemix payment covers the cost of all services including the botulinum toxin and stimulator needles.

How will the TAC fund injections provided by a private hospital?

When a client is admitted for a day procedure in a private hospital and theatre charges are incurred, the TAC can pay for botulinum toxin medication as an additional charge. The theatre fees paid to a private hospital cover the cost of all equipment and consumables (including stimulator needles) that are used in theatre.

What item numbers should be used for botulinum toxin injections?

Medical practitioners with the right of private practice can raise a charge for the treatment they provide in relation to botulinum toxin. The TAC recognises the items listed in the Medicare Benefits Schedule (MBS) specific to treatment with botulinum toxin. The fees for these items are paid in accordance with the TAC fee schedule for medical practitioner services.

As currently there are no MBS items for botulinum toxin injections in the management of upper limb spasticity, the TAC can pay the equivalent of the MBS item number 18354. For use of botulinum toxin to treat bladder instability, use MBS item number 18360.

However, payment for more than one item will only be made when distinctly different muscle groups are injected. That is, muscle groups that perform different functions, eg. the calf and forearm (to a maximum of 2 groups per session).

Can the TAC fund botulinum toxin prescribed or administered by a member of a client's immediate family?

Refer to the Funding Treatment by a Member of a Client's Immediate Family policy.

In relation to botulinum toxin, what will the TAC not fund?

The TAC will not fund:

  • botulinum toxin for a person other than the injured client
  • botulinum toxin for a condition that existed prior to the transport accident or that is not a direct result of a transport accident
  • treatment or services where there is no objective evidence that a treatment or service is safe and effective
  • treatment of bladder instability using botulinum toxin injections more than once in any 6 month period
  • botulinum toxin in any situation where prior written approval is required and has not been given, except for contracture control within the first 18 months post-accident
  • botulinum toxin where it is being requested for conditions other than those listed in this policy, eg. for pain. Refer to the Non-Established, New or Emerging Treatments and Services policy
  • items outside of the Medicare Benefit Schedule with the above exceptions
  • the cost of botulinum toxin medication administered to a public hospital in-patient as this is covered by the casemix funding
  • treatment or services provided outside the Commonwealth of Australia
  • fees associated with non-attendance
  • the cost of telephone calls and telephone consultations between providers and clients, and between different providers, including hospitals
  • botulinum toxin provided more than 2 years prior to the request for funding except where the request for payment is made within 3 years of the transport accident. Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy.

 


Medical Services Reimbursement Rates

The TAC has adopted the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for services provided by medical practitioners.  When invoicing for medical services, medical practitioners are expected to adhere to the MBS rules unless otherwise specified by the TAC in the Reimbursement Rates for Medical Services booklet or its medical policies.

The Reimbursement Rates for Medical Services booklet below must be read in conjunction with:

Current Rates

Previous Rates

At the time of production this publication contained up to date information as released by Medicare Australia (Medicare).  The relevant publication will be updated to reflect any further changes that are implemented by Medicare each year.  Please check our website for the latest version.

If you have any questions about these publications or the reimbursement rates, please contact the TAC on 1300 654 329. Alternatively, e-mail info@tac.vic.gov.au.