MedicaidPrior AuthMedium impact
MAB2021110802
Pennsylvania Medicaid (DHS)·PA · Neurology, Dermatology, PM&R (Physical Medicine & Rehab) +1 more·Provider Bulletin
Effective date
Jan 3, 2022
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid updated prior authorization requirements for Botulinum Toxins (Type A and Type B), adding new medical necessity criteria including FDA-approved indications, age-appropriate dosing, contraindication checks, and specific treatment failure requirements for various conditions. All prescriptions for Botulinum Toxins must be prior authorized through Pennsylvania's Medical Assistance program.
Action Required
By January 3, 2022: Billing and clinical teams must update prior authorization procedures for all Botulinum Toxin prescriptions in Pennsylvania Medicaid cases. Ensure documentation includes: FDA-approved indication or medically accepted use, age-appropriate dosing, contraindication screening, injection site mapping with doses, and condition-specific requirements (therapeutic failure history for non-preferred products, oral medication trials for spasticity in adults 18+, topical agent failure for hyperhidrosis, preventive medication trials for chronic migraine). Update EMR templates to capture required documentation elements. Prior authorization requests missing these elements will be denied.