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.