A patient with headache on most days of the month has been told by her neurologist that Botox is the next step, and by her plan’s phone line that it “may require prior authorization.” She wants to know one thing before she books anything: is it covered, or is she about to be handed a bill? For chronic migraine the answer is usually yes, with conditions attached, and the conditions are where most of the delays and denials live. This post walks through what the plans require, why claims get denied and how they get fixed, what the treatment costs if a plan will not pay, and how long the whole process takes at Modal Pain Management in Midtown Manhattan.
What “covered” means for Botox: a drug and a procedure
Botox for migraine is two things on a claim. The drug — 155 units of onabotulinumtoxinA — is billed under your medical benefit, either from the physician’s stock or, on some plans, supplied through a specialty pharmacy that ships it to the office. The procedure — 31 injections across seven muscle groups of the head and neck, the fixed PREEMPT map — is billed separately as the injection service. Prior authorization covers both, and a denial on either half stalls the whole thing. That is why “is it covered?” has a two-part answer: the indication has to be right, and the paperwork has to match the plan’s rules for both pieces.
The indication comes from the FDA label and the International Classification of Headache Disorders. Botox is approved for the prevention of headaches in adults with chronic migraine, headache on 15 or more days a month lasting four hours a day or longer (AbbVie 2024), and ICHD-3 defines chronic migraine as headache on 15 or more days a month for more than three months with migraine features on at least 8 of them (ICHD-3, 2018). The evidence behind the indication is the PREEMPT program, 1,384 adults with chronic migraine, in whom headache days fell by 8.4 a month at 24 weeks with Botox against 6.6 with placebo (Dodick 2010). The label states that safety and effectiveness have not been established in episodic migraine, 14 or fewer headache days a month, across seven placebo-controlled studies (AbbVie 2024), and Aetna, for one, lists episodic migraine as experimental (Aetna 2026).
What authorizations usually ask for
Plans differ in wording and thresholds, but most requests are built around the same facts.
Headache days. Fifteen or more a month, for more than three months. The plan wants a headache diary, not an estimate. If you do not keep one, start today. A calendar app with a mark on every headache day is enough.
Migraine days. At least 8 of those days have to carry migraine features: one-sided or throbbing pain, moderate to severe intensity, worse with routine activity, nausea, sensitivity to light and sound, or aura — or respond to a triptan. Daily headache without those features is chronic tension-type headache, cervicogenic headache, or medication-overuse headache, and Botox is not approved for it. Aetna, for one, lists tension-type and cervicogenic headache as experimental (Aetna 2026).
Duration. The label, and plans such as UnitedHealthcare and Aetna, describe headaches lasting four hours or longer (AbbVie 2024, UnitedHealthcare 2026, Aetna 2026). Short, stabbing, or minutes-long headaches are a different diagnosis.
Preventive trials, on some plans. Aetna asks for an adequate trial of two preventive medicines from at least two classes, at least 60 days each: antidepressants, antiepileptics, beta-blockers, or a CGRP-targeting drug, with a contraindication counting in place of a trial (Aetna 2026). The current UnitedHealthcare and Anthem policies set no prior-medication requirement for chronic migraine (UnitedHealthcare 2026, Anthem 2026). The American Headache Society now counts CGRP-targeting therapies as a first-line option for prevention, without a requirement to fail other classes first (Charles 2024). Anthem’s policy also sets terms for patients who stay on a CGRP drug while adding Botox (Anthem 2026).
One thing that does not disqualify anyone: medication overuse. In the PREEMPT trials, 65% of patients met criteria for acute medication overuse, and in that group headache days still fell more with Botox than with placebo, by 8.2 against 6.2 a month (Silberstein 2013). It is addressed at the same visit, with a taper planned alongside the injections, but it does not close the door. Whether you meet these criteria takes two minutes to check with our chronic migraine Botox eligibility check.
Why claims get denied, and how they get fixed
In our experience, most denials are not a disagreement about whether you have chronic migraine. They are documentation problems, and each one has a fix.
The diary is missing or thin. The plan sees “patient reports frequent headaches” and denies for lack of a 15-day count. The fix is a three-month diary, which is also the reason we ask for it before submitting rather than after a denial.
On plans that require them, the preventive trials are undocumented, too short, or from one class. Under a policy like Aetna’s, each trial needs at least 60 days unless a contraindication applies, and two beta-blockers count as one class. The fix is a medication history with drug, dose, duration, and outcome for each trial, which the consultation builds with you.
The diagnosis code is wrong. A claim coded as episodic migraine, tension-type headache, or unspecified headache is likely to be denied. The fix is a diagnosis of chronic migraine supported by the exam and the diary.
The drug came through the wrong channel. Plans differ in whether the office buys the drug and bills for it or a specialty pharmacy ships it for your session. The fix is knowing the plan’s rule before the first session, which the benefits check establishes.
The renewal was not justified. Renewals ask for evidence that treatment helped. Aetna renews when monthly headache frequency has fallen since treatment started, and Anthem approves the first 6 months, then wants fewer migraine days or severe migraine days, plus another meaningful benefit (Aetna 2026, Anthem 2026). The fix is the same diary, kept through treatment.
A peer-to-peer review, Dr. Movshis on the phone with the plan’s medical director, can often settle what the paperwork does not, usually inside the original 7–14 business-day window.
What it costs if the plan will not pay, or you would rather not wait
Self-pay Botox for chronic migraine at Modal Pain Management is $2,000 per session for the 155-unit PREEMPT protocol, all-inclusive: the physician fee, the 31 injections, and the drug. Sessions are every 12 weeks, so a year of treatment is four sessions. The self-pay pricing page also lists the per-unit prices of Botox, Dysport, and Daxxify for the other indications. Payment plans through Cherry, including 0%-APR options on shorter terms, are available through our financing page. HSA and FSA cards are accepted.
Two things to know about the insured route. First, the manufacturer’s savings program (the Botox Savings Program, now part of BOTOX Complete) reimburses part of the out-of-pocket cost of the drug for eligible patients with commercial insurance, and our office checks eligibility with you. It is not available to patients on government plans. Second, your deductible status matters more than the plan’s coverage decision for what you actually pay in the first cycle. Ask for the benefits check before you schedule, and you will know both numbers before the first injection. We check your benefits and go over what your plan covers and any expected cost by phone before your visit, so there are no surprise bills.
The timeline at Modal Pain Management
The consultation takes 45–60 minutes and may include an ultrasound exam. Bring your headache diary, your preventive-medication history with doses and durations, and any imaging. Dr. Movshis examines for the headaches that mimic migraine. The one that starts at the base of the skull and never switches sides is often cervicogenic. Botox is not the treatment for it, and a third occipital nerve block, covered on its own criteria, is the usual first test. If the diagnosis is chronic migraine and your plan’s criteria are met, the authorization is submitted the same day. Approval typically takes 7–14 business days, and the first session is generally scheduled within 2–3 weeks of the visit. The session takes about 15 minutes. The 74-second film shows what the injections do at the nerve endings, and the Botox for chronic migraine page covers the protocol, the side effects, and what to expect over the first three cycles.
If you are not sure which side of the 15-day line you are on, keep the diary for a month and take the eligibility check. If you already know, the consultation is the next step, and verifying your insurance before it means the authorization starts the day you are seen.
References
- AbbVie. BOTOX (onabotulinumtoxinA) for injection: full prescribing information, section 1.3 (chronic migraine), Medication Guide revised 10/2024. DailyMed, U.S. National Library of Medicine. Accessed October 10, 2026. DailyMed
- Aetna. Clinical Policy Bulletin 0113: Botulinum Toxin. Last reviewed July 14, 2026. Aetna
- Anthem (Elevance Health). Medical Drug Clinical Criteria CC-0032: Botulinum Toxin. Published January 30, 2026. CarelonRx
- Charles AC, Digre KB, Goadsby PJ, Robbins MS, Hershey A. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: an American Headache Society position statement update. Headache. 2024;64(4):333–341. doi:10.1111/head.14692 · PubMed
- Dodick DW, Turkel CC, DeGryse RE, et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program. Headache. 2010;50(6):921–936. doi:10.1111/j.1526-4610.2010.01678.x · PubMed
- Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211. doi:10.1177/0333102417738202 · PubMed
- Silberstein SD, Blumenfeld AM, Cady RK, et al. OnabotulinumtoxinA for treatment of chronic migraine: PREEMPT 24-week pooled subgroup analysis of patients who had acute headache medication overuse at baseline. J Neurol Sci. 2013;331(1–2):48–56. doi:10.1016/j.jns.2013.05.003 · PubMed
- UnitedHealthcare. Commercial Medical Benefit Drug Policy 2026D0017AN: Botulinum Toxins A and B. Effective January 1, 2026. UHCprovider.com
Frequently Asked Questions
For chronic migraine, usually yes, with prior authorization. Botox has an FDA indication for preventing headaches in adults with chronic migraine, 15 or more headache days a month with headaches lasting 4 hours a day or longer (AbbVie 2024). Each plan writes its own criteria. Aetna, for example, also requires trials of two preventive medicine classes, while the current UnitedHealthcare and Anthem policies do not. Coverage for episodic migraine, tension-type headache or cervicogenic headache is unlikely, and Aetna lists them as experimental (Aetna 2026). Modal Pain Management accepts most commercial PPO plans and does not accept Medicare, Medicaid, HMO plans, or workers' compensation. Our office checks your plan's policy and submits the request.
It depends on your plan's deductible and coinsurance, and on whether the drug runs through your medical benefit or a specialty pharmacy, so there is no single number for everyone. Three things lower the cost for commercially insured patients: prior authorization approved before the first session, so nothing is billed as unauthorized, the manufacturer's savings program (the Botox Savings Program, now part of BOTOX Complete), which reimburses part of the out-of-pocket drug cost for eligible commercially insured patients, and knowing your deductible status before you start, since the first round of the plan year often lands on it. We check your benefits and go over what your plan covers and any expected cost by phone before your visit, so there are no surprise bills.
At Modal Pain Management the self-pay price for the 155-unit PREEMPT protocol is $2,000 per session, all-inclusive: the physician fee, the 31 injections, and the drug. Sessions are every 12 weeks, so a full year is four sessions. Payment plans through Cherry are available, and HSA and FSA cards are accepted. Self-pay is the route patients take when a plan requirement is not met yet, or when they prefer to skip the authorization step.
In our experience, most denials are documentation problems rather than disagreements about the diagnosis. The headache diary is missing or does not show 15 headache days a month. Where the plan requires preventive trials, they are undocumented, too short or all from one class. Aetna, for example, asks for at least 60 days of each (Aetna 2026). The claim is coded as episodic migraine, tension-type headache or unspecified headache rather than chronic migraine. Or a renewal request did not show the drop in headache days the plan asks for. Each of these is fixable with the right paperwork, which is why our office builds the request from your diary and medication history.
After the consultation our office submits the prior authorization with your diagnosis, headache diary, and medication history. Approval typically takes 7–14 business days, and the first injection session is generally scheduled within 2–3 weeks of the visit. If the plan asks for more information, a peer-to-peer review with Dr. Movshis can often settle it within the same window. Renewals depend on your diary showing fewer headache days. Anthem, for example, approves the first 6 months and then asks for fewer migraine days or severe migraine days, plus another meaningful benefit (Anthem 2026). Keep the diary going through treatment so the renewal is ready when it is due.
It depends on the plan. Aetna asks for an adequate trial, at least 60 days each, of two preventive medicines from at least two classes: antidepressants such as amitriptyline or venlafaxine, antiepileptics such as topiramate or divalproex, beta-blockers such as propranolol or metoprolol, or a CGRP-targeting drug. A contraindication counts in place of a trial (Aetna 2026). The current UnitedHealthcare and Anthem policies set no prior-medication requirement for chronic migraine (UnitedHealthcare 2026, Anthem 2026). The American Headache Society counts CGRP-targeting drugs as a first-line option for prevention (Charles 2024). Our office checks your own plan's policy at the consultation.
