LCD for Botulinum Toxin Type A (L1321)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L1321 

 

LCD Title 

Botulinum Toxin Type A 

 

Contractor's Determination Number 

1321 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

 

CMS National Coverage Policy 

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

CMS Pub 100-2, 15, §50, 17-§10

Medicare Carriers Manual, Section 2050.5(A) 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
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Maryland
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North Carolina
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New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 12/27/1996  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 10/01/2006  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

Botulinum toxin is a complex protein produced by the anaerobic bacterium Clostridium. Botulinum Toxin Type A injections are used to treat various focal muscle spastic disorders and excessive muscle contractions such as dystonias, spasms, twitches, etc. They produce a presynaptic neuromuscular blockade by preventing the release of acetylcholine from the nerve endings. The resulting chemical-denervation of muscle produces local paresis or paralysis and allows individual muscles to be weakened selectively. It has the advantage of being a potent neuromuscular blocking agent with good selectivity, duration of action, with the smallest antigenicity, and fewest side effects.

Before consideration of coverage may be made, it should be established that the patient(s) has been unresponsive to conventional methods of treatments such as medication, physical therapy and other appropriate methods used to control and/or treat spastic conditions.

Coverage of Botulinum Toxin Type A for certain spastic conditions (e.g., cerebral palsy, stroke, head trauma, spinal cord injuries, and multiple sclerosis), will be limited to those conditions listed in the Covered ICD-9 section of this policy. All other uses in the treatment of other types of spasm, including smooth muscle types, will be considered as investigational and therefore, noncovered by Medicare.

Botulinum Toxin Type A can be used to reduce spasticity or excessive muscular contractions to relieve pain; to assist in posturing and walking; to allow better range of motion; to permit better physical therapy; to reduce severe spasm in order to provide adequate perineal hygiene.

Due to the uncommonness of organic writer’s cramp, Medicare would not expect to see the treatment of this condition to be billed frequently.

There may be patients who require electromyography in order to determine the proper injection site (s). The electromyography procedure codes specified in the HCPCS section of this policy may be covered if the physician has difficulty in determining the proper injection site.

The patient who has a spastic or excessive muscular contraction condition is usually started with a low dose of Botulinum Toxin A (10 units) and the accepted maximum dosage per site is about 25 units. Other spastic or muscular contraction conditions, such as, eye muscle disorders, (e.g., blepharospasm) may require lesser amounts such as only 1-2 units. For larger muscle groups, it is generally agreed that once a maximum of 25 units per site has been reached and there is no response, the treatment is discontinued. The treatments may be resumed at a later date. With response, the effect of the injections generally lasts for 3 months at which time the patient may need repeat injections to control the spastic or excessive muscular condition. It is usually considered not medically necessary to give Botulinum Toxin Type A injections for spastic or excess muscular contraction conditions more frequently than every 90 days, unless acceptable justification is documented for more frequent use in the initial therapy.

Coverage of treatments provided may be continued unless any two treatments in a row, utilizing an appropriate or maximum dose of Botulinum Toxin Type A failed to produce satisfactory clinical response. Providers must also document the results of and the response to these injections after every third session.

Requests may be considered for continued treatment during a treatment period or for resumption at a later date if satisfactory results have not been obtained, if compelling clinical evidence of medical necessity is presented.

Medicare will allow payment for one injection per site regardless of the number of injections made into the site. A site is defined as including muscles of a single contiguous body part, such as, a single limb, eyelid, face, neck etc,

Medicare will allow payment for the treatment of achalasia when dilatation and/or myotomy is specifically contraindicated.

Irritable colon, biliary dyskinesia or any treatment of other spastic conditions not listed as covered in this policy are considered to be cosmetic, investigational (including the treatment of smooth muscle spasm), not safe and effective, and are not accepted as the standard of practice within the medical community.

Treatment of severe primary axillary hyperhidrosis. For purposes of this policy, severe primary hyperhidrosis is defined as a condition involving focal, visible and severe sweating of at least 6 months duration without apparent cause that has at least 2 of the following characteristics: (1) sweating is bilateral and relatively symmetric, (2) impairs daily activities, (3) episodes occur at least once per week, (4) the age of onset was less than 25 years, (5) there is a positive family history, and (6) focal sweating stops during sleep. Treatment of severe primary axillary hyperhidrosis will be considered as medically reasonable and necessary only for patients in whom the axillary hyperhidrosis is barely tolerable or intolerable and frequently or always interferes with daily activities in spite of optimal treatment with topical agents, such as prescription-strength aluminum chloride, or who could not tolerate these agents.

Treatment of medically significant sialorrhea. Limited coverage exists for medically significant sialorrhea. Injection into salivary glands will be covered when there is documentation that:
1. A medically significant condition of sialorrhea exists, either on a primary (overproduction) basis or due to conditions (e.g. Parkinson's Disease) that interfere with normal swallowing mechanisms. The medical record must show that the condition is medically significant, i.e. that adverse health outcomes such as recurrent perioral skin breakdown or recurrent aspiration pneumonia are caused by or significantly worsened by the presence of the sialorrhea. The existence of drooling as a social or caretaker concern does not qualify as medically significant.
2. The patient has failed to respond to a reasonable trial of less invasive means, including pharmacotherapy (unless contraindicated) and at least one other approach such as speech therapy, behavioral therapy or other non-pharmacologic means.
Dosages are expected to conform to recommended levels for the threatment of this conditon; greater than 100 U (cumulatively across all glands at a single session) will not be considered medically necessary. The medical record is expected to show documented evidence of improvement beyond the subjective assessment that drooling has decreased. 

 

Coverage Topic 

Lab Services
 

 

Coding Information

Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

 

Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

0250

Pharmacy-general classification

0636

Drugs requiring specific identification-detailed coding (eff 3/92)

 

 

CPT/HCPCS Codes 

 

J0585

BOTULINUM TOXIN TYPE A, PER UNIT

J3490

UNCLASSIFIED DRUGS

The following procedures are to be reported with the respective listed covered ICD-9-CM diagnosis code: (See Coding Guidelines for correct reporting of services)

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

46505

CHEMODENERVATION OF INTERNAL ANAL SPHINCTER

64612

CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL NERVE (EG, FOR BLEPHAROSPASM, HEMIFACIAL SPASM)

64613

CHEMODENERVATION OF MUSCLE(S); NECK MUSCLE(S) (EG, FOR SPASMODIC TORTICOLLIS, SPASMODIC DYSPHONIA)

64614

CHEMODENERVATION OF MUSCLE(S); EXTREMITY(S) AND/OR TRUNK MUSCLE(S) (EG, FOR DYSTONIA, CEREBRAL PALSY, MULTIPLE SCLEROSIS)

64650

CHEMODENERVATION OF ECCRINE GLANDS; BOTH AXILLAE

67345

CHEMODENERVATION OF EXTRAOCULAR MUSCLE

92265

NEEDLE OCULOELECTROMYOGRAPHY, ONE OR MORE EXTRAOCULAR MUSCLES, ONE OR BOTH EYES, WITH INTERPRETATION AND REPORT

95860

NEEDLE ELECTROMYOGRAPHY; ONE EXTREMITY WITH OR WITHOUT RELATED PARASPINAL AREAS

95861

NEEDLE ELECTROMYOGRAPHY; TWO EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS

95869

NEEDLE ELECTROMYOGRAPHY; THORACIC PARASPINAL MUSCLES (EXCLUDING T1 OR T12)

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)

 

 

ICD-9 Codes that Support Medical Necessity 

 

333.6

GENETIC TORSION DYSTONIA

333.71

ATHETOID CEREBRAL PALSY

333.79

OTHER ACQUIRED TORSION DYSTONIA

333.81

BLEPHAROSPASM

333.82

OROFACIAL DYSKINESIA

333.83

SPASMODIC TORTICOLLIS

333.84

ORGANIC WRITERS' CRAMP

333.89

OTHER FRAGMENTS OF TORSION DYSTONIA

334.1

HEREDITARY SPASTIC PARAPLEGIA

340

MULTIPLE SCLEROSIS

341.0 - 341.9

NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED

342.11

SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE

342.12

SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE

343.0 - 343.9

CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED

344.00 - 344.5

QUADRIPLEGIA UNSPECIFIED - UNSPECIFIED MONOPLEGIA

351.8

OTHER FACIAL NERVE DISORDERS

378.00 - 378.9

ESOTROPIA UNSPECIFIED - UNSPECIFIED DISORDER OF EYE MOVEMENTS

478.75

LARYNGEAL SPASM

527.7

DISTURBANCE OF SALIVARY SECRETION

530.0

ACHALASIA AND CARDIOSPASM

564.6

ANAL SPASM

565.0

ANAL FISSURE

705.21

PRIMARY FOCAL HYPERHIDROSIS

723.5

TORTICOLLIS UNSPECIFIED

728.85

SPASM OF MUSCLE

729.89

OTHER MUSCULOSKELETAL SYMPTOMS REFERABLE TO LIMBS

787.20

DYSPHAGIA, UNSPECIFIED

787.21

DYSPHAGIA, ORAL PHASE

787.22

DYSPHAGIA, OROPHARYNGEAL PHASE

787.23

DYSPHAGIA, PHARYNGEAL PHASE

787.24

DYSPHAGIA, PHARYNGOESOPHAGEAL PHASE

787.29

OTHER DYSPHAGIA

 

 

Diagnoses that Support Medical Necessity 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity 

 

 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 

 

 

Diagnoses that DO NOT Support Medical Necessity 

 

 

General Information

Documentation Requirements 

Documentation should include the following elements:

 

  • support for the medical necessity of the Botulinum Toxin A injection
  • a covered diagnosis
  • a statement that traditional methods of treatments have been tried and proven unsuccessful
  • dosage and frequency of the injections
  • support for the medical necessity of electromyography procedures
  • support of the clinical effectiveness of the injections
  • specify the site(s) injected


Due to the short life of the botulinum toxin, Medicare will reimburse the unused portion of this drug, only when the vial is not split between patients, However, documentation must show in the patients medical record the exact dosage of the drug given and the exact amount of the discarded portion of the drug. 

 

Appendices 

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:

Frequently Asked Questions


 

 

Utilization Guidelines 

 

 

Sources of Information and Basis for Decision 

AMA Drug Evaluation, Vol 1, Neurolytic Drugs, 2:21-23

Annals OtoRhinoLaryngology, 103(1): 31-35, Jan.’94, (Cricopharyngeal)

Annals Neurology, 28:512-5, 1990(Spasticity)

Neurology, 184(43): 183-185, Jan. ‘93 (Writer’s Cramp)

NEJM, 332(12): 774-816, March ‘95 (Achalasia)

Carrier policies 

 

Advisory Committee Meeting Notes 

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives. 

 

Start Date of Comment Period 

 

 

End Date of Comment Period 

 

 

Start Date of Notice Period 

11/27/1996 

 

Revision History Number 

26 

 

Revision History Explanation 

05/16/2006 added CPT/HCPCS codes 46505, 64650, 95873,95874 to Group 2
04/24/2006 deleted CPT/HCPCS code 64640 from Group 2

03/24/2005 Added 64614 to CPT/HCPCS codes group 2, added 705.21 to ICD-9 Codes that Support Medical Necessity Group 1, added corresponding text to Indications and Limitations of Coverage and Billing and Coding Guidelines.

07/24/2002 Formatted

01/05/2001 Updated ICD-9, HCPCS, and CPT codes with 2001 code books

11/26/2005 - The description for CPT/HCPCS code 31570 was changed in group 2
11/26/2005 - The description for CPT/HCPCS code 31571 was changed in group 2
11/26/2005 - The description for CPT/HCPCS code 64613 was changed in group 2

11/26/2005 - CPT/HCPCS code 90782 was deleted from group 2
11/26/2005 - CPT/HCPCS code 90799 was deleted from group 2

This LCD was converted from an LMRP on 12/6/2005

09/04/2006 - This policy was updated by the ICD-9 2006-2007 Annual Update.

09/12/2006 - Medically significant sialorrhea was added to the indications.

09/03/2007 - This policy was updated by the ICD-9 2007-2008 Annual Update.

10/02/2007 - Frequently Asked Questions restored to Appendices. 

 

Reason for Change 

ICD9 Addition/Deletion
 

Last Reviewed On Date 

10/02/2007 

 

Related Documents 

Article(s)
A37873 - Botulinum Toxin Type A

 

LCD Attachments 

FAQ (895 bytes)

 

Other Versions 

Updated on 10/02/2007 with effective dates 10/01/2006 - N/A

Updated on 09/26/2006 with effective dates 10/01/2006 - N/A

Updated on 09/12/2006 with effective dates 10/01/2006 - N/A

Updated on 09/01/2006 with effective dates 05/16/2006 - 09/30/2006

Updated on 05/16/2006 with effective dates 05/16/2006 - N/A

Updated on 04/24/2006 with effective dates 04/24/2006 - 05/15/2006

Updated on 12/06/2005 with effective dates 12/07/2005 - 04/23/2006

Updated on 12/06/2005 with effective dates 03/29/2005 - 12/06/2005

Updated on 03/24/2005 with effective dates 03/24/2005 - 03/28/2005

Updated on 10/13/2003 with effective dates 07/24/2002 - 03/23/2005

Updated on 03/11/2003 with effective dates 07/24/2002 - N/A

Updated on 02/15/2003 with effective dates 07/24/2002 - N/A

Updated on 10/21/2002 with effective dates 07/24/2002 - N/A

Updated on 10/04/2002 with effective dates 07/24/2002 - N/A