1.0 CPT 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) 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.
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
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 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 code 64653). Effective January 1, 2011, use
CPT 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.