(104) Accessing Pelvic Floor Botox Through Insurance

Abstract Introduction Chronic pelvic pain is common, affecting up to 1 in 6 Americans assigned female at birth (AFAB) and up to 1 in 4 people AFAB globally. Of those living with chronic pelvic pain, 50%-90% have myofascial pelvic pain or hypertonic pelvic floor (HPF). First line treatment for HPF generally involves pelvic floor physical therapy (PFPT). For severe cases for muscle hypertonicity and spasticity, botulinum toxin injections are a useful adjunctive treatment. By blocking the release of the acetylcholine (ACh), a necessary neurotransmitter for muscle contraction, botulinum toxin prevents muscle contraction and spasm. This, in turn, reduces pain caused by muscle hypertonicity and spasm, which can facilitate patient functioning and ability to progress in PFPT. While botulinum toxin is not currently FDA-approved for the treatment of pelvic floor hypertonicity or spasticity, it is FDA-approved to treat muscle spasticity in other parts of the body (specifically upper and lower extremity muscles). There is also robust data supporting its off-label use to treat spasticity in other muscle groups and myofascial pain. Despite its utility, botulinum toxin is often financially inaccessible as a treatment option. Without insurance coverage, the average cost of botulinum toxin starts around 10-15 per unit, with a typical dose of 100 units exceeding 1000. Currently, there is no available data about the financial accessibility of botulinum toxin as a treatment tool for HPF. Objective This study sought to determine the costs to patients receiving botulinum toxin for the treatment of HPF within the insurance model. Methods Prior to treatment with botulinum toxin injections, prior authorization was obtained. Data was collected using the slicer-dicer feature in Epic (electronic medical records system). Patient who received botulinum toxin injections for the treatment of HPF between 8/2023 to 6/2025 were included based on HCPCS code J0585 and CPT code 64646. Payment information including total payer allowance, coinsurance, and copay was used to determine total costs for each patient. Results In total, 122 patients were treated with botulinum toxin injections across 176 patient encounters between 8/2023 to 6/2025. Of those, 119 patients were commercially insured, 3 patients had Medicare or Medicaid. Patient cost, which was determined by the sum of coinsurance + copay, ranged from 0 to 410. 96. The average patient cost was 53. 62 for botulinum toxin treatment. Out of the total 176 patient encounters, 65 resulted in no cost to the patient (0) after insurance coverage. Conclusions Despite its utility in treating muscle hypertonicity and spasticity, botulinum toxin is a cost prohibitive treatment. A standard dose of 100 units to treat HPF would exceed 1000 out of pocket. In order to provide appropriate, accessible care in treating HPF, botulinum toxin should be available and covered through insurance. These results demonstrate that while botulinum toxin remains off-label for the treatment of HPF, it can be utilized within the insurance model to provide affordable care. Disclosure No.