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.