California doctor gets 15 years for $45M Medicare Botox fraud: what chronic migraine claims need

On October 30, 2026, the Justice Department announced that California doctor Violetta Mailyan had been sentenced the day before, October 29, to 15 years in prison. DOJ says she used her medical practice to bill Medicare more than $45 million for Botox injection services that were medically unnecessary and never provided. HHS-OIG also listed the case on its enforcement actions page.

DOJ's release makes a point that matters to every coder who handles these claims: Medicare reimburses Botox injections when they are necessary to treat documented cases of chronic migraine. The case is a reminder of what that documentation is supposed to look like.

What the jury decided and what the court ordered

Mailyan, 45, of Glendale, California, owned and operated Healthy Way Medical Center, which DOJ describes as a clinic that purported to provide beauty and cosmetic services. After a six-day jury trial that ended in May 2026, she was convicted of nine counts of wire fraud and three counts of obstruction of a criminal investigation of a health care offense. The jury also found that she used fraud proceeds to buy two Tesla vehicles and five pieces of California real estate.

HHS-OIG and the FBI investigated the case, and the Fraud Division's Health Care Fraud Section prosecuted it.

What DOJ says the trial evidence showed

The figures and details in this section come from DOJ's summary of court documents and evidence presented at trial.

According to DOJ, Mailyan billed and was paid for thousands of injections that fell into three groups: injections that were never provided, injections provided only for cosmetic purposes, and injections given to patients whose primary care physicians hadn't referred them for treatment of chronic migraine. DOJ says she billed for thousands of injections, representing more than $19 million, on days her clinic was closed. She also billed for injections while she was on vacation in Mexico, Hawaii, Las Vegas, Pennsylvania and New York. In one example, DOJ says she billed more than $200,000 for Botox services in California while she was in Cabo.

DOJ also says that when she realized investigators were closing in, she falsified medical records and forged beneficiary signatures, including for a man who was in federal prison at the time she claimed to have treated him, and gave those records to investigators to make it look as though she had seen patients she hadn't seen.

What Noridian's LCD requires for chronic migraine

California is in Medicare jurisdiction JE, where Noridian Healthcare Solutions is the Medicare Administrative Contractor. Noridian's LCD L35170, Botulinum Toxin Injections, is the current policy for California, Nevada, Hawaii, American Samoa, Guam and the Northern Mariana Islands. Its current revision took effect for services on or after February 22, 2026. DOJ's release doesn't give the years of the scheme, so this section describes the policy in effect today, not the version that applied to her claims.

Under the LCD, the requirements for a first round of injections for chronic migraine prophylaxis include:

• The injections are used only for chronic migraine prophylaxis.
• The patient has 15 or more headache days a month, with 8 or more of them migraine days.
• The migraines last 4 hours or more on a migraine day, and the headaches have been present for at least 3 months.
• The patient has had an inadequate response to a 2-month trial, at the usual effective dose, of at least one drug in two of the listed classes (antidepressants, beta blockers, calcium channel blockers and antiepileptics), or can't take them.
• The headaches cause an objective, significant functional disability and are of moderate to severe intensity, and the toxin is FDA approved for chronic migraine prophylaxis.

The LCD adds conditions for patients who also use a CGRP drug, and it says the objective assessment must be documented at baseline and at each follow-up using the same scale.

For later rounds, the record has to show at least a 50 percent drop in monthly migraine headache days and in migraine episodes, a significant reduction in headache-related disability with objective improvement in function, and that biobehavioral therapy was assessed and used as appropriate. The LCD says injections aren't reasonable and necessary for episodic migraine prophylaxis, tension headaches or chronic daily headaches, or at onabotulinumtoxinA doses above 195 units. It also points to Medicare's cosmetic surgery exclusion in the Benefit Policy Manual, Chapter 16, section 120.

Other MACs publish their own botulinum toxin LCDs, so check the policy for your jurisdiction in the Medicare Coverage Database.

What the billing and coding article asks for

Noridian's companion billing and coding article A57185 says that when documentation doesn't establish medical necessity, the services will be denied as not reasonable and necessary. For botulinum toxin, it says the record should include a covered diagnosis, the dose, sites and frequency of injection, and a description of how well the treatment worked.

The article also addresses wasted drug. The JW modifier reports the amount discarded from a single-dose container, and the JZ modifier attests that none was discarded. If leftover toxin is used for cosmetic purposes, the article says the provider must not bill Medicare for it with JW or JZ and must explain in the record where, why and how much was used.

Group 6 of the article lists 44 ICD-10-CM codes under its chronic migraine heading. That list includes all eight chronic migraine codes in the FY 2027 ICD-10-CM code descriptions file, which you can also read in the Code Book or check in the Encoder:

Group 6 also includes other migraine codes, but a code on the list doesn't meet the LCD by itself. The LCD covers chronic migraine prophylaxis and says episodic migraine prophylaxis isn't reasonable and necessary, so the note has to support chronic migraine and the criteria above.

The procedure and drug codes for these injections are listed in the article itself. HCC Buddy's Encoder and Code Book cover ICD-10-CM only, so use the MAC article and CMS files for those codes.

Red flags this case puts on a coder's desk

A diagnosis code on the claim isn't enough. The visit note has to show the headache-day counts, the duration, the prior drug trials and, for repeat rounds, the measured response. A date of service on a day the clinic was closed, or when the rendering provider wasn't there, is the kind of mismatch DOJ says ran through this case. You can look up a rendering provider's NPPES record with our NPI lookup.

For another recent sentencing built on documentation that didn't match the care, see our report on the DMERx orthotics case. For a drug billing angle, see OIG's review of HCPCS codes that didn't match the NDC crosswalk.