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TRICARE Policy Manual 6010.60-M, April 1, 2015
Medicine
Chapter 7
Section 27.1
Botulinum Toxin Injections
Issue Date:  October 12, 1998
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-1, March 10, 2017
1.0  CPT PROCEDURE CODES
46505, 64611 - 64614, 64640, 64653, 67345
2.0  HCPCS Procedure Codes
J0585 - J0588
3.0  DESCRIPTION
These procedures involve the injection of small amounts of botulinum toxin into selected muscles for the nonsurgical treatment of the conditions relating to spasticity, various dystonias, nerve disorders, and muscular tonicity deviations.
4.0  POLICY
4.1  Botulinum toxin A (AbobotulinumtoxinA/OnabotulinumtoxinA/IncobotulinumtoxinA), Botulinum toxin B (RimabotulinumtoxinB), and any other Federal Drug Administration (FDA) approved botulinum toxin injectable drugs may be considered for cost-sharing for their FDA approved indications, unless otherwise excluded by the program.
4.2  Botox® (OnabotulinumtoxinA-chemodenervation-Current Procedural Terminology (CPT) procedure code 46505) may be considered for off-label cost-sharing for the treatment of chronic anal fissure unresponsive to conservative therapeutic measures, effective May 1, 2007.
4.3  Botulinum toxin A injections may be considered for off-label cost-sharing for the treatment of spasticity resulting from Cerebral Palsy (CP), effective November 1, 2008.
4.4  Botox® (OnabotulinumtoxinA) and Myobloc® (RimabotulinumtoxinB) injections may be considered for off-label cost-sharing for the treatment of sialorrhea associated with Parkinson’s disease patients who are refractory to, or unable to tolerate, systemic anticholinergics, effective October 1, 2009.
4.5  Botox® (OnabotulinumtoxinA) injections for laryngeal dystonia (adductor spasmodic dysphonia) and oromandibular dystonia (jaw-closing dystonia) may be considered for cost-sharing.
4.6  Botox® (OnabotulinumtoxinA) injections may be considered for off-label cost-sharing for the treatment of palmar hyperhidrosis that is refractory to topical and pharmacological therapies, effective January 1, 2013.
4.7  Off-label use. Effective July 27, 2012, off-label uses of Botulinum toxin A (AbobotulinumtoxinA/OnabotulinumtoxinA/IncobotulinumtoxinA), Botulinum toxin B (Rimabotulinumtoxin B), and any other FDA approved botulinum toxin injectable drugs may be approved for cost-sharing by the contractor in accordance with Chapter 8, Section 9.1, paragraph 2.2.5.
5.0  Exclusions
5.1  Botulinum toxin A injections are unproven for the following indications:
•  Lower back pain/lumbago.
•  Episodic migraine, chronic daily headache, cluster headache, cervicogenic headache, and tension-type headache.
5.2  Botox® (OnabotulinumtoxinA-chemodenervation-CPT procedure code 64612) for the treatment of muscle spasms secondary to cervical degenerative disc disease and spinal column stenosis is unproven.
5.3  Botulinum toxin A used for cosmetic indications (e.g., frown lines and brow furrows) is excluded from coverage.
6.0  Effective Dates
6.1  May 1, 2007, for coverage of chronic anal fissure unresponsive to conservative therapeutic measures (CPT procedure code 46505).
6.2  October 1, 2009, for coverage of sialorrhea associated with Parkinson’s disease patients who are refractory to, or unable to tolerate, systemic anticholinergics (CPT procedure code 64653). Effective January 1, 2011, use CPT procedure code 64611.
6.3  November 14, 1990, for coverage of laryngeal or oromandibular dystonia.
6.4  January 1, 2013, for coverage of palmar hyperhidrosis that is refractory to topical and pharmacological therapies.
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