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Botulinum Toxin Injection Criteria

Approved: 8/06
Reviewed: 3/14, 1/15, 2/15, 12/15, 1/17
Revised: 2/22/07, 2/08, 1/09, 3/10, 2/11, 1/12, 1/13, 3/14, 7/14, 2/15, 12/15

 

Botulinum is a drug derived from a powerful toxin that has a paralytic effect when injected into muscles.  There are two types of botulinum toxins, Type A (Occulinumâ or Botoxâ) and Type B (Myoblocâ).  Type A and Type B may be used to treat focal muscle spastic disorders and excessive muscle contractions associated with cerebral palsy, stroke, head trauma, spinal cord injuries, and multiple sclerosis.  Such conditions include:

  • Anal spasm
  • Anal fissure when unresponsive to conservative therapeutic measures
  • Blepharospasm
  • Cervical dystonia
  • Esophageal achalsia
  • Facial myokymia
  • Focal Hyperhydrosis with medical complications
  • Hirschsprung’s disease
  • Laryngeal spasm
  • Limb spasticity
  • Post-facial nerve palsy synkinesis (hemifacial spasms)
  • Ptyalism
  • Strabismus in children when other treatments have failed
  • Idiopathic torsion dystonia
  • Orofacial dyskinesia
  • Dystonia
  • Stroke related hemiplegia
  • Melkersson’s syndrome
  • Spastic dysphonia
  • Sialorrhea
  • Intractable migraine and mixed headache refractory to all other modalities of treatment
  • Chronic migraine appearing 15 days per month with headache lasting longer than four hours.
  • Other disorders as specified on the Medicare Wisconsin Physicians Services lists will be considered after medical necessity review, see addendum 

The following guidelines are used when considering the medical approval of Botulinum toxin injections: 

  1. Diagnosis
  2. Documentation to support medical necessity
  3. Dosage to be administered per injection and site(s) of injection
  4. A description of improvement in the patient’s functional status for requests of additional treatment
  5. Periodic medical review

 

 


Addendum

 

CPT/HCPCS Codes

 

31513

Laryngoscopy, Indirect; With Vocal Cord Injection

31570

Laryngosopy, Direct; With Injection Into Vocal Cord(s), Therapeutic

31571

Laryngoscopy, Direct; With Injection Into Vocal Cord(s), Therapeutic;   With Operating Microscope or Telescope

43201

Esophagoscopy, Flexible, Transoral; With Directed Submucosal   Injection(s), Any Substance

43236

Esophagogastroduodenoscopy, Flexible, Transoral; With Directed   Submucosal Injection(s), Any Substance.

46505

Chemodenervation of Internal Anal Sphincter

52287

Cystourethroscopy, With Injection(s) for Chemodenervation of The   Bladder

64611

Chemodenervation of Parotid and Submandibular Salivary Glands, Bilateral

64612

Chemodenervation of Muscle(s); Muscle(s) Innervated by Facial Nerve,   Unilateral (eg, for Blepharospasm, Hemifacial Spasm)

64615

Chemodenervation of Muscle(s); Muscle(s) Innervated by Facial,   Trigeminal, Cervical Spinal and Accessary Nerves, Bilateral (eg, for Chronic   Migraine)

64616

Chemodenervation of Muscle(s); Neck Muscle(s), Exluding Muscles of the   Larynx, Unilateral (eg, for Dsytonia, Spasmodic, Torticollis)

64617

Chemodenervation of Muscle(s); Larynx, Unilateral, Percutaneous (eg,   For Spasmodic Dysphonia), Includes guidance by needle electromyography, when   performed

64642

Chemodenervation of one extremity; 1-4 Muscle(s)

64643

Chemodenervation of One Extremity; Each Additional Extremity, 1-4   Muscle(s) (List Separately in Addition to Code for Primary Procedure)

64644

Chemodenervation of One Extremity; 5 or more muscle(s)

64645

Chemodenervation of One Extremity; Each Additional Extremity, 5 or More   Muscle(s) (List Separately In Addition to Code for Primary Procedure)

64646

Chemodenervation of Trunk Muscle(s); 1-5 Muscle(s)

64647

Chemodenervation of Trunk Muscle(s); 6 or More Muscle(s)

64650

Chemodenervation of Eccrine Glands; Both Axillae

64653

Chemodenervation of Eccrine Glands; Other Area(s), (eg, scalp, face,   neck), per day

67345

Chemodenervation of Extraocular Muscle

92265

Needle Oculoelectromyography, 1 or More Extraocular Muscles, 1 or More   Both Eyes, With Interpretation and Report

95873

Electrical Stimulation for Guidance in Conjuction With Chemodenervation   List Separately in Addition to Code for Primary Procedure)

95874

Needle Electromyography for Guidance in Conjunction with   Chemodenervation (List Separately in Addition to Code for Primary Procedure)

J0585

Injection, Onabotulinumtoxina, 1 unit

J0586

Injection, Abobotulinumtoxina, 5 units

J0587

Injection, Rimabotulinumtoxinb, 100 units

J0588

Injection, Incobotulinumtoxin A, 1 unit

 ICD-9 Codes that Support Medical Necessity

 

Procedure  

Code

 

ICD-10 Code

 

Description

31513

31570

31571

Or

64617

 

 

J38.0   –J38.02

J38.5

R47.1

R47.8

R47.89

Paralysis   of vocal cords

Laryngeal   Spasm

Dysarthria

Other   Speech Disturbance

43201

K22.0

Achalasia   and cardio

43236

K22.0

Achalasia   and cardio

52287

G83.4

N32.81

N31.9

N31.9

N31.9

N39.41

R35.0

Cauda   Equina Syndrome with Neuogenic Bladder

Hypertonicity   of bladder

Neurogenic   bladder NOS

Detrusor   Sphincter Dyssynergia

Other   Functional Disorder of Bladder

Urge   Incontinence

Urinary   Frequency

64611

G20.

K11.2   – K11.20

K11.7

Paralysis   Agitans

Sialoadenitis

Disturbance   of salivary secretion

64612

G24.5

G24.4

G81.12

G81.14

G81.11

G81.13

G81.10

G51.8

H02.04   –H02.049

 

Blepharospasm

Orofacial   Dyskinesia

Spastic   Hemiplegia affecting left dominant side

Spastic   Hemiplegia affecting left nondominant side

Spastic   Hemiplegia affecting left dominant side

Spastic   Hemiplegia affecting left nondominant side

Spastic   Hemiplegia affecting unspecified side

Other   Facial Nerve Disorders

Spastic   Entropion

 

64615

G43.709

G43.719

G43.701

G43.711

Chronic   Migraine w/o Aura, not intractable, w/o stat Migr

Chronic   Migrain w/o Aura, intractable, w/o stat Migr

Chronic   Migraine w/o Aura, not intractable, w stat Migr

Chronic   Migraine w/o Aura, Intractable, So Stated, w status migrainosus

 

 

 

64616

G24.1

G80.3

G24.02

G24.9

G24.3

G24.9

M43.6

Q68.0

Genetic   Torsion Dystonia

Athetoid   Cerebral Palsy

Acute   Dystonia Due to Drugs

Other   Acquired Torsion Dsytonia

Spasmodic   Torticollis

Other   Fragments of Torsion Dystonia

Torticollis   Unspecified

Congenital   Musculoskeletal Deformities of Sternocleidomastoid Muscle

 

 

 

64642

64643

64644

64645

64646

64647

R25.1

G25.69

G24.1

G80.3

G24.02

G24.8

G25.89

G24.

G27.9

G24.9

G11.4

G35.

G36.0

G37.8

G37.8

G37.9

G81.1

G81.10

G81.12

G81.14

G81.11

G81.13

G80.1

G80.2

G80.8

G80.8

G82.50

G82.51

G82.52

G82.52

G82.54

G82.54

G82.20

G83.0

G83.10

G83.12

G83.14

G83.11

G83.13

G83.20

G83.22

G83.24

G83.21

G83.23

G83.3

I69.91

I69.959

 

I69.951

 

I69.952

 

I69.953

 

I60.954

 

I69.91

I69.961

 

I69.962

 

I69.965

 

N31.9

N36.44

 

L74.51

M62.838

R29.898

R25.

R35.0

 

Tremor,   unspecified

Tics   of Organic Origin

Genetic   Torsion Dsytonia

Athetoid   Cerebral Palsy

Drug   induced acute dystonia

Other   Acquired  Torsion Dystonia

Organic   writer’s cramp

Dystonia

Dystonia,   unspecified

Other   Fragments of Torsion Dystonia

Hereditary   Spastic Paraplegia

Multiple   Sclerosis

Neuromyelitis   optica

Schilder’s   Disease

Other   demyelinating disease of central nervous system

Demyelinating   disease of central nervous system, unspecified

Spastic   hemiplegia

Spastic   hemiplegia, affecting unspecified site

Spastic   hemiplegia, affecting left dominant site

Spastic   hemiplegia, affecting left non-dominant site

Spastic   hemiplegia, affecting right dominant site

Spastic   hemiplegia, affecting right non-dominant site

Diplegic,   congenital

Spastic   Hemiplegic cerebral palsy

Other   cerebral palsy

Other   specific cerebral palsy

Qudraplegia,   unspecified

Quadriplegia,   C1-4 complete

C1-C4,   complete

C1-C4,   incomplete

C5-C7,   complete

C5-C7,   incomplete

Paraplegia,   unspecified

Diplegia   of upper limb

Monoplegia   of lower limb, affecting unspecified side

Monoplegia   of lower limb, affecting left dominant side

Monoplegia   of lower limb, affecting left nondominant side

Monoplegia   of lower limb, affecting right dominant side

Monoplegia   of lower limb, affecting right nondominant side

Monoplegia   of upper limb, affecting unspecified side

Monoplegia   of upper limb, affecting left dominant side

Monoplegia   of upper limb, affecting left nondominant side

Monoplegia   of upper limb, affecting right dominant side

Monoplegia   of upper limb, affecting right nondominant side

Unspecified   monoplegia

Cognitive   deficits following unspecified cerebrovascular disease

Hemiplegia   and hemiparesis following unspecified cerebrovascular disease Affecting   Unspecified Side

Hemiplegia   and hemiparesis following unspecified cerebrovascular disease affecting right   dominant side

Hemiplegia   and hemiparesis following unspecified cerebrovascular disease affecting left   dominant side

Hemiplegia   and hemiparesis following unspecified cerebrovascular disease Affecting right   Nondominant Side

Hemiplegia   and hemiparesis following unspecified cerebrovascular disease Affecting left   Nondominant Side

Cognitive   deficits following unspecified cerebralvascular disease

Other   Paralytic Syndrome following cerebralvascular disease  Affecting Right Dominant Side

Other   Paralytic Syndrome following cerebralvascular disease Affecting Left Dominant   Side

Other   Paralytic Syndrome following unspecified cerebralvascular disease, Bilateral

Neuromuscular   dysfunction of bladder, unspecified

Muscular   disorders of urethra

 

Primary   focal hyperhidrosis

Other   muscle spasm

Other   symptoms and signs involving the musculoskeletal system

Abnormal   involuntary movements

Frequency   of Micturition

64650

Or

64653

L74.51

Primary   focal hyperhidrosis

67345

H50.0

H50.00   – H50.08

H50.10   – H50.18

H50.30   -  H50.34

H50.40   – H50.43

H50.50   – H50.55

H78.50

H49.00

H49.10

H49.20

H49.40

H49.30

H50.60

H50.611  

H50.612

H50.69

H50.811

H50.812

H50.89

H51.0

H51.11

H51.12

H51.8

H51.20

H51.9

Esotropia

Esotropia,   Unspecified – Alternating Esotropia With Other Noncomitancies

 

Exotropia,   Unspecified – Alternating Exotropia With Other Noncomitancies

 

Intermittent   Heterotropia Unspecified – Intermittent Exotropia Alternating

 

Heterotropia   Unspecified – Accomadative Component In Esotropia

 

Heterophoria   Unspecified – Alternating Hyperphoria

 

Paralytic   Strabismus, Unspecified Eye

Third   (oculomotor) nerve palsy, unspecified eye

Fourth   (oculomotor) nerve palsy, unspecified eye

Sixth   (abducent) nerve palsy, unspecified eye

Progressive   external ophthalmoplegia, unspecified eye

Total   (external opthalmoplegia, unspecified eye

Mechanical   Strabismus, unspecified

Brown   Sheath Syndrome, Right eye

Brown   Sheath Syndrome, Left eye

Other   Mechanical Strabismus

Duane’s   Syndrome, Right eye

Duane’s   Syndrome, Left eye

Other   Specified Strabimus

Palsy   (spasm) of conjugate gaze

Convergence   Insufficiency

Convergence   Excess

Other   Specified disorders of Binocular Movement

Internuclear   opthalmoplegia, unspecified eye

Unspecified   Disorder of Binocular Movement

 

46505

K60.2

Anal   Fissure

 

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