Mountain State Medical Policy Bulletin
Section: Injections
Number: I-11
Topic: Botulinum Toxin (Chemodenervation)
Effective Date: January 1, 2006
Issued Date: January 2, 2006
Date Last Reviewed: 01/2006

General Policy Guidelines

Indications and Limitations of Coverage

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)
  • Demyelinating disease of central nervous system, unspecified (341.9)
  • Diplegia of upper limbs (344.2)
  • Facial spasms (351.0-351.9)
  • Hemifacial spasms (351.8) 
  • Hereditary spastic paraplegia (334.1)
  • Hyperhidrosis, primary, axilla (705.21)
    Considered medically necessary when the patient has severe, primary axillary hyperhidrosis involving focal, visible and excessive sweating of at least six months duration without apparent cause that includes all of the following characteristics:

• Sweating is bilateral and relatively symmetrical
• Sweating significantly impairs daily activities
• Episodes occur at least once per week
• The age of onset is less than 25 years
• Focal sweating stops during sleep

The patient must be classified as “severe” or a “4” on the Hyperhidrosis Disease Severity Scale prior to treatment for primary axillary hyperhidrosis. This is a four-point scale that includes the following:

1 - sweating is never noticeable and never interferes with daily activities
2 - sweating is tolerable but sometimes interferes with daily activities
3 - sweating is barely tolerable and frequently interferes with daily activities
4 - sweating is intolerable and always interferes with daily activities

The patient must have documented treatment with 10-35% aluminum chloride of at least six months duration that failed to reduce the severity index scale before the initiation of botulinum toxin type A injections.

  • Idiopathic torsion dystonia (333.6)
  • Infantile cerebral palsy (343.0-343.9)
  • Laryngeal spasm (478.75)
  • Late effects of cerebrovascular disease (438.20-438.22, 438.30-438.32, 438.40-438.42, 438.50-438.53)
  • Monoplegia of lower limb (344.30-344.32)
  • Monoplegia of upper limb (344.40-344.42) 
  • Multiple sclerosis (340)
  • Neuromyelitis optica (341.0)
  • Organic writer's cramp (333.84)
  • Orofacial dyskinesia (333.82)
  • Other demyelinating diseases of central nervous system (341.8)
  • Paraplegia (344.1)
  • Quadriplegia and quadriparesis (344.00-344.09)
  • 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
  • Unspecified monoplegia (344.5) 

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 botulinum toxin type A or botulinum toxin type B is reported for other conditions not listed on this policy, it should be denied as not medically necessary. The appropriate chemodenervation code (46505, 64612, 64613, 64614, 64650, 64653, 64999, 67345, S2340, S2341) would also be denied if the drug is not covered. 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 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.

Procedure Codes

465056461264613646146465064653
6499967345J0585J0587S2340S2341

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

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
12/2005, Botulinum toxin type A allowed for more conditions

References

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

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[Version 002 of I-11]
[Version 001 of I-11]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.