Dysport® (abobotulinumtoxinA)
EVICORE-MEDICAL_DRUG-23A69E03
Dysport is covered only for the listed indications — FDA‑approved uses (adult cervical dystonia; upper and lower limb spasticity for patients ≥2 years) and specified compendial off‑label adult uses (blepharospasm, hemifacial spasm, chronic anal fissure, chronic sialorrhea, oromandibular dystonia) — and is not covered for unlisted indications, with age limits (most adult indications ≥18 years; spasticity ≥2 years). Approvals are for 12 months and require documentation of diagnosis, patient age (and pediatric weight), planned dose/route/sites, prior botulinum toxin treatment dates, and adherence to indication‑specific dosing maxima, administration routes, and minimum retreatment intervals (generally 12–16 weeks).
"Chronic anal fissure dosing limitation: recommended dose maximum 100 units administered no more frequently than every 12 weeks"
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