Mountain State Medical Policy Bulletin |
Section: | Injections |
Number: | I-11 |
Topic: | Botulinum Toxin (Chemodenervation) |
Effective Date: | January 1, 2010 |
Issued Date: | May 3, 2010 |
Date Last Reviewed: |
Indications and Limitations of Coverage
Botulinum toxin type A and B are chemically, pharmacologically, and clinically distinct products and are not interchangeable. FDA labeling states that "units of biological activity cannot be compared to nor converted into units of any other botulinum toxin or any toxin assessed with any other specific assay method." Onabotulinum Toxin Type A (BOTOX®)
Abobotulinum Toxin Type A (Dysport™ ) Rimabotulinum Toxin Type B (MYOBLOC®) Cervical dystonia, also known as spasmodic torticollis, 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 onabotulinum toxin type A, abobotulinum toxin type A, or rimabotulinum 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 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 should be maintained in the provider's records. 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. |
|
46505 | 64612 | 64613 | 64614 | 64650 | 64653 |
64999 | 67345 | J0585 | J0586 | J0587 | S2340 |
S2341 |
Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. |
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 Dystonia Study Group. Comparison of Botulinum Toxin Serotypes A and B for the Treatment of Cervical Dystonia. Neurology, 2005; 65 Prescribing Information. Botox, October 2006. Allergan Pharmaceuticals. Irvine, CA Comparison of Botulinum Neurotoxin Preparations for the Treatment of Cervical Dystonia. Clinical Therapeutics. 2007: 29(7) FDA Notifies Public of Adverse Reactions Linked to Botox Use, FDA News. Rockville, MD: FDA, February 3, 2008 Marchetti A, Magar R, Findley L, et al. Retrospective evaluation of the dose of Dysport and BOTOX in the management of cervical dystonia and blepharospasm: The REAL DOSE study. Movement Disorders. 2005;20(8):937-944. Wenzel R, Jones D, Borrego JA. Comparing two botulinum toxin type A formulations using manufacturers' product summaries. J Clin Pharm and Thera. 2007;32:387-402. Brashear A. Clinical comparisons of botulinum neurotoxin formulations. The Neurologist. 2008;14:289-298. Myobloc® [package insert]. South San Francisco, CA: Solstice Neurosciences, Inc; 07/2009. BOTOX® [package insert]. Irvine, CA: Allergan, Inc; 07/2009. Dysport® [package insert]. Wrexham, UK: Ipsen Biopharm Ltd; 05/2009. |
[Version 008 of I-11] |
[Version 007 of I-11] |
[Version 006 of I-11] |
[Version 005 of I-11] |
[Version 004 of I-11] |
[Version 003 of I-11] |
[Version 002 of I-11] |
[Version 001 of I-11] |
For procedure code J0585
333.6 | 333.71 | 333.72 | 333.79 |
333.81 | 333.82 | 333.83 | 333.84 |
333.85 | 334.1 | 340 | 341.0 |
341.1 | 341.8 | 341.9 | 342.11 |
342.12 | 343.0 | 343.1 | 343.2 |
343.3 | 343.4 | 343.8 | 343.9 |
344.00 | 344.01 | 344.02 | 344.03 |
344.04 | 344.09 | 344.1 | 344.2 |
344.30 | 344.32 | 344.40 | 344.41 |
344.42 | 344.5 | 351.0 | 351.1 |
351.8 | 351.9 | 378.00 | 378.10 |
378.20 | 378.30 | 378.31 | 378.40 |
378.41 | 378.42 | 378.43 | 378.50 |
378.51 | 378.52 | 378.53 | 378.54 |
378.55 | 378.56 | 378.60 | 378.61 |
378.62 | 378.63 | 378.73 | 378.9 |
438.20 | 438.21 | 438.22 | 438.30 |
438.31 | 438.32 | 438.40 | 438.41 |
438.42 | 438.50 | 438.51 | 438.52 |
438.53 | 478.75 | 478.79 | 530.0 |
565.0 | 705.21 | 723.5 | 784.49 |
For procedure codes J0586 and J0587
333.83 |