1.0 CPT
PROCEDURE CODES
46505, 64611 - 64614, 64640,
64653, 67345
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.