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April 21, 2022

Botulinum Toxin Injections

Botulinum toxins are potent neuromuscular blocking agents that are useful in treating various focal muscle spastic disorders and excessive muscle contractions, such as dystonia, spasms, and twitches. They produce a presynaptic neuromuscular blockade by preventing the release of acetylcholine from the nerve endings. Since the resulting chemical denervation of muscle produces local paresis or paralysis, selected muscles can be treated. Botulinum toxins are used in the treatment of overactive skeletal muscles, smooth muscles, and glands.

Coverage

Effective for dates of service July 1, 2020, and after, hospital outpatient department (HOPD) providers will need to obtain prior authorization (PA) for botulinum toxin injections if performed in a HOPD setting and billed with one of the following CPT codes.

Code	Description
J0585	Injection, onabotulinumtoxin a
J0586	Injection, abobotulinumtoxin a
J0587	Injection, rimabotulinumtoxin b
J0588	Injection, incobotulinumtoxin a

PA for botulinum toxin for the above CPT codes is required when used in conjunction with one of the following CPT codes.

Code	Description
64612	Injection of chemical for destruction of nerve muscles on one side of face
64615	Injection of chemical for destruction of facial and neck nerve muscles on both sides of face

Documentation requirements

Documentation recommended for the support of botulinum toxin injections includes:

Covered diagnosis;
Dosage and frequency of planned injections;
Documentation to support the medical necessity when electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s), (when applicable);
Documentation of the clinical effectives of the injections (for continuous treatment);
Specific site(s) injections (refer to MACs LCD/LCA);
Documentation of the management of a chronic migraine diagnosis. A medical record must include a history of migraine and experiencing frequent headaches on most days of the month;
Documentation of traditional treatment such as medication, physical therapy, and other appropriate methods have been tried and proven unsuccessful (when applicable).

Best practice/documentation feedback/tips and help

Botulinum toxins are available under different trade names. Each trade name corresponds to a specific CPT code that requires PA. The chart below identifies which trade name corresponds to the CPT codes.

BOTOX	J0585
Allergan	J0585
Dysport	J0586
Myobloc	J0587
Xeomin	J0588

If botulinum toxin is being used to treat chronic migraines, documentation should support that headache occurred greater than 15 days in one month and that 8 of the headaches were migraines. Evidence of conservative treatment tried and proven unsuccessful should be documented.

Continuous treatment of botulinum toxin will be considered medically reasonable and necessary when the following are supported in the documentation:

Injections have been administered approximately 90 days apart.
Injection sites that correlate to the administration CPT code and treatment diagnosis. If the internal protocol is not well known, please include an injection site map to support the requested code(s)
Evidence of effectiveness for the last two injections.
- It is not expected that the most recent injection provided will show effectiveness since the patient has not returned for their next appointment.

References

The A/B Medicare Administrative Contractor Prior Authorization Collaboration Workgroup developed this document. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and assists the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.