Chemodenervation refers to the use of chemical agents to produce neuromuscular blockade for the purpose of selective weakening of specific muscles, or muscle groups. This policy applies to the use of neurotoxins as well as other chemical agents used for this purpose.

Chemodenervation techniques are indicated for:

1. Chemodenervation of muscle innervated by the facial nerve in the management of blepharospasm or hemifacial spasm.
2. Chemodenervation of cervical spinal muscles in the management of spasmodic torticollis.
3. Chemodenervation of extremity muscles in the management of dystonias, cerebral palsy and multiple sclerosis.
4. Chemodenervation of extraocular muscles in the management of strabismus.
5. Chemodenervation of the lower esophageal sphincter in the management of achalasia.
6. Chemodenervation of laryngeal muscles in the treatment of adductor spasmodic dysphonia.
7. Chemodenervation of bilateral frontalis, trapezius, temporalis, sternocleidomastoid, and splenium capitis muscles for treatment of chronic tension headache, chronic migraine, and intractable daily headache.
8. Chemodenervation of axillary sweat glands for the treatment of severe primary axillary hyperhidrosis that is inadequately managed with topical agents. Severe is defined for this purpose as level 3 (underarm sweating barely tolerable/frequently interferes with daily activities) or level 4 (underarm sweating intolerable/always interferes with daily activities) on the Hyperhidrosis Disease Severity Scale (HDSS).
9. Chemodenervation of the internal anal sphincter for the treatment of chronic anal fissure.

Services for all other conditions, as well as services performed with excessive frequency, will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Limitations
Chemodenervation for the treatment of headaches is limited to patients who experience headaches that may result in permanent cerebral dysfunction, or who are intractable because they cannot tolerate or do not benefit from standard therapies. Candidates for this treatment are patients with:

1. Intractable migraine (with or without aura);
2. Intractable chronic tension-type headache with moderate to severe pain;
3. Chronic daily headaches defined as patients experiencing more than 15 days of headache per month either migraine or tension-type features.

Intractable headache is defined as a patient meeting one of the following criteria for treatment:

1. Failed trials of at least three preventive pharmacologic migraine therapies (e.g. beta-blockers, calcium channel blockers, anticonvulsants, antidepressants) with or without concomitant behavioral and physical therapies, after titration to maximal tolerated doses or have medical contraindications to common therapies or who cannot tolerate common preventative therapies; or,
2. Experience chronic daily headaches or recurrent headaches at least twice per month causing disability lasting three or more days per month; or,
3. Standard abortive medication is required more than twice per week, or is contraindicated, ineffective or not tolerated.

Chemodenervation treatment has a variable lasting beneficial effect from twelve to sixteen weeks, following which the procedure may need to be repeated. It is appropriate to inject the lowest clinically effective dose at the greatest feasible interval that results in the desired clinical result.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently  than generally accepted by peers and the reason for additional services is not justified by documentation.

Documentation Requirements

The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available on request.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Use code 95873 and 95874 in addition to code for primary procedure (codes 64612-64614).

Codes 64612, 64613, 64614, or 67345 are bilateral codes. These codes may be submitted with the following modifiers:

• CPT modifier 50 (Bilateral Procedure)
• HCPCS modifiers RT (Right Side) and LT (Left Side)

If multiple body regions are injected on the same date of service, by the same provider, the total dosage injected must be submitted on the same line of the claim.

Use code J3590 (unclassified biologics) for incobotulinumtoxin A; Xeomin.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Internet-Only Manual (IOM), Pub. 100-2, Medicare Benefit Policy, Chapter 15, Section 50.4

IOM, Pub. 100-3, Medicare National Coverage Determinations, Chapter 1, Section 160.1

Use of these codes does not guarantee reimbursement. The patient’s medical record must document that the coverage criteria in this policy have been met.

Codes 43201, J0585, J0586, J0587, J3590

Codes 46505, J0585, J0586, J0587, J3590

Codes 64612, J0585, J0586, J0587, J3590

Codes 64613, J0585, J0586, J0587, J3590

Codes 64614, J0585, J0586, J0587, J3590

Codes 64650, J0585, J0586, J0587, J3590

Codes 67345, J0585, J0586, J0587, J3590