Botulinum Toxin Injections

PA is only required when one of the required Botulinum Toxin codes (J0585, J0586, J0587, or J0588) is used in conjunction with one of the required CPT injection codes (64612, injection of chemical destruction of nerve muscles on one side of face, or 64615, injection of chemical for destruction of facial and neck nerve muscles on both sides of face). Use of these Botulinum Toxin codes in conjunction/paired with procedure codes other than 64612 or 64615 will not require PA under this program.

General Documentation Requirements for Botulinum Toxin Injections:

  • Support of medical necessity of the botulinum toxin (type A or type B) injection;
  • A covered diagnosis;
  • Dosage and frequency of the injections;
  • Support for the medical necessity of electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s) (when applicable);
  • Support of clinical effectiveness of the injections (for continuous treatment);
  • Specific site(s) injected;
  • For support of management of a chronic migraine diagnosis, the Medical Record must include a history of migraine and experiencing headaches on most days of the month;
  • A statement that traditional methods of treatments such as medication, physical therapy, and other appropriate methods have been tried and proven unsuccessful (when applicable)

Coverage Criteria

Codes

Code Description
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 accessory nerves, bilateral (eg, for chronic migraine)
J0585 Injection, onabotulinumtoxina, 1 unit
J0586 Injection, abobotulinumtoxina, 5 units
J0587 Injection, rimabotulinumtoxinb, 100 units
J0588 Injection, incobotulinumtoxin a, 1 unit

 

The Prior Authorization for Certain Hospital Outpatient Department Part B Associated Codes List is in Appendix B of the CMS OPD Operational Guide.

Resources

 

Last Updated Mon, 10 Jan 2022 19:52:16 +0000