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Botulinum Toxin Injection Criteria

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 Hyperhidrosis 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.

·         Urgency of urination

·         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

Laryngoscopy, 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 (e.g., for Blepharospasm, Hemifacial Spasm)

64615

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

64616

Chemodenervation of Muscle(s); Neck Muscle(s), Excluding Muscles of the Larynx, Unilateral (e.g., for Dystonia, Spasmodic, Torticollis)

64617

Chemodenervation of Muscle(s); Larynx, Unilateral, Percutaneous (e.g., 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), (e.g., 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 Conjunction 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-10 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

R39.15

Cauda Equina Syndrome with Neurogenic Bladder

Hypertonicity of bladder

Neurogenic bladder NOS

Detrusor Sphincter Dyssynergia

Other Functional Disorder of Bladder

Urge Incontinence

Urinary Frequency

Urgency of Urination

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 Migrainosus

Chronic Migraine w/o Aura, intractable, w/o stat Migrainosus

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

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 Dystonia

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 Dystonia

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

Diplegia, congenital

Spastic Hemiplegic cerebral palsy

Other cerebral palsy

Other specific cerebral palsy

Quadriplegia, 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 cerebrovascular disease

Other Paralytic Syndrome following cerebrovascular disease  Affecting Right Dominant Side

Other Paralytic Syndrome following cerebrovascular disease Affecting Left Dominant Side

Other Paralytic Syndrome following unspecified cerebrovascular 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 – Accommodative Component In Esotropia

 

Heterophoria Unspecified – Alternating Hyperphoria

 

Paralytic Strabismus, Unspecified Eye

Third (oculomotor) nerve palsy, unspecified eye

Fourth (oculomotor) nerve palsy, unspecified eye

Sixth (abducens) 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 Strabismus

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

K60.1

K59.4

Anal Fissure

Chronic Anal Fissure

Anal Spasm

 

Approved:  8/06

Reviewed: 3/14, 1/15, 2/15, 12/15, 1/17, 1/18, 3/19

Revised: 2/22/07, 2/08, 1/09, 3/10, 2/11, 1/12, 1/13, 3/14, 7/14, 2/15, 12/15, 3/19, 2/20

 

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