Botulinum Toxin Type A

Botulinum toxin type A, BOTOX®, (J0585) is eligible when it's used in the treatment of any of the following conditions. If this treatment is reported for conditions other than those listed below, it should be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

• Achalasia (530.0)
  In patients who have not responded to dilation therapy or who are considered poor surgical candidates
• Anal fissure (565.0)
• Blepharospasm (333.81)
• Facial spasms (351.0-351.9)
• Hemifacial spasms (351.8) 
• Hereditary spastic paraplegia (334.1)
• Hyperhidrosis, primary, axilla (705.21)
  Considered medically necessary only in the small subset of patients with medical complications, such as skin maceration with secondary infections
• Idiopathic torsion dystonia (333.6)
• Infantile cerebral palsy (343.0-343.9)
• Laryngeal spasm (478.75)
• Neuromyelitis optica (341.0)
• Organic writer's cramp (333.84)
• Orofacial dyskinesia (333.82)
• Schilder's disease (341.1)
• Spasmodic dysphonia (478.79, 784.49)
• Spasmodic torticollis (333.83)
• Spastic hemiplegia (342.11-342.12)
• Strabismus (378.00, 378.10, 378.20, 378.30, 378.31, 378.40-378.43, 378.50-378.56, 378.60-378.63, 378.73, 378.9)
• Symptomatic torsion dystonia (333.7)
• Torticollis (723.5)
  Whether congenital, due to childbirth injury or traumatic

Botulinum Toxin Type B

Botulinum toxin type B, MYOBLOC™, (J0587) is eligible for the treatment of patients with cervical dystonia.

Cervical dystonia, also known as spasmodic torticollis (333.83), is a neurological movement disorder in which a person's neck and shoulder muscles have contractions that force the head and neck into abnormal and sometimes painful positions.

If this treatment is reported for other conditions, it should be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Description

Normal muscle movement occurs when a nerve sends a chemical signal to a muscle, which makes it contract. The nerve ending is separated from the muscle by a small gap called the neuromuscular junction. The chemical signal, acetylcholine, travels across the gap and causes a muscle contraction. Some neurological diseases cause muscle spasms, tightness, or pain.

Chemodenervation (64612, 64613, 64614, 64999, 67345, S2340, S2341) is a procedure whereby small amounts of botulinum toxin are injected into excessively contracted muscles. Botulinum toxin prevents the release of the chemical signal, which leads to muscle relaxation. Unlike surgical denervation, chemodenervation is not permanent, although the effect lasts for months.

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.

PRN References

03/1995, Chemodenervation
12/1997, Chemodenervation (Botulinum toxin type A) coverage outlined
08/1998, Chemodenervation (Botulinum toxin type A) coverage is expanded
04/1999, Botulinum toxin type A
02/2001, Botulinum toxin type A now eligible for chronic anal fissures
10/2001, Botulinum toxin type B now eligible for cervical dystonia

Safety and Efficacy of NeuroBloc (Botulinum Toxin Type B) in Type A-resistant Cervical Dystonia, Neurology, Vol. 53, October 1999

Safety and Efficacy of NeuroBloc (Botulinum Toxin Type B) in Type-A responsive Cervical Dystonia, Neurology, Vol. 53, October 1999

The Safety and Efficacy of Botulinum Toxin Type B in the Treatment of Patients with Cervical Dystonia: Summary of Three Controlled Clinical Trials, Neurology, Vol. 55, January 2000