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Contractor Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LCD Database ID Number

L2874

LCD Title

Botulinum Toxin Type A

Contractor's Determination Number

96-03-R2

AMA/CPT and ADA/CDT Copyright Statement

CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply. CDT-4 codes and descriptions are Ó2004 American Dental Association. All rights reserved.

CMS National Coverage Policy

• Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines
• 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). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

Oversight Region

Region III

CMS Consortium

Northeast

DMERC Region LCD Covers

N/A

Original Determination Effective Date

10/12/1996

Revision Effective Date

10/01/2004

08/27/2002

Indications and Limitations of Coverage and/or Medical Necessity

Description

Botulinum toxin type A is a drug that has a paralytic effect when injected into muscles. The drug causes a localized denervation of the muscle by inhibiting the release of acetylcholine Advantage can be taken of the neuromuscular blocking effect to alleviate muscle spasms due to excessive neural activity of central origin, or to weaken a muscle for therapeutic purposes.

Indications and Limitations

· Local injections of Botulinum toxin type A are effective in the treatment of a variety of conditions which cause muscle spasticity or excessive muscular contractions.

· Coverage is reasonable and necessary after patients have been shown to have had an inadequate response to conventional therapies (i.e. medication, physical therapy, etc.).

· Dosage will be based on the size of muscle group effected and the degree of spasticity.

· Generally, treatment with Botulinum toxin is not necessary more frequently than every 90 days.

· The cost of special syringes is not separately payable.

Coverage Topics

Outpatient Hospital Services

Bill Type Codes

13X, 22X, 23X, 74X, 75X, 83X

Revenue Codes

636

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book or the HCPCS Level II book for the long description.

J0585 Botulinum toxin A, per unit

Does the “CPT 30% Coding Rule” Apply”

N/A

ICD-9 Codes that Support Medical Necessity

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid. Further, these ICD-9-CM codes can be used only with the conditions listed in the “Indications and Limitations” sections of this policy.

Medicare is establishing the following limited coverage

333.6	Idiopathic torsion dystonia
333.7	Symptomatic torsion dystonia
333.81	Blepharospasm
333.82	Orofacial dyskinesia
333.83	Spasmodic torticollis
333.84	Organic writer's cramp
333.89	Other fragments of torsion dystonia
334.1	Hereditary spastic paraplegia
340	Multiple sclerosis
341.0	Neuromyelitis optica
341.1	Shilder's disease
341.8	Other demyelinating diseases of central nervous system
341.9	Demyelinating disease of central nervous system, unspecified
342.10	Spastic hemiplegia, affecting unspecified side
342.11	Spastic hemiplegia, affecting dominant side
342.12	Spastic hemiplegia, affecting nondominant side
343.0	Diplegic
343.1	Hemiplegic
343.2	Quadriplegic
343.3	Monoplegic
343.4	Infantile hemiplegia
343.8	Other specified infantile cerebral palsy
343.9	Infantile cerebral palsy, unspecified
344.00	Quadriplegia unspecified
344.01	C1-C4 complete
344.02	C1-C4 incomplete
344.03	C5-C7 complete
344.04	C5-C7 incomplete
351.8	Other facial nerve disorders
351.9	Facial nerve disorder, unspecified
378.00	Esotropia, unspecified
378.01	Monocular esotropia
378.02	Monocular esotropia with A pattern
378.03	Monocular esotropia with V pattern
378.04	Monocular esotropia with other noncomitancies
378.05	Alternating esotropia
378.06	Alternating esotropia with A pattern
378.07	Alternating esotropia with V pattern
378.08	Alternating esotropia with other noncomitancies
378.10	Exotropia, unspecified
378.11	Monocular exotropia
378.12	Monocular exotropia with A pattern
378.13	Monocular exotropia with V pattern
378.14	Monocular exotropia with other noncomitancies
378.15	Alternating exotropia
378.16	Alternating exotropia with A pattern
378.17	Alternating exotropia with V pattern
378.18	Alternating exotropia with other noncomitancies
378.20	Intermittent heterotropia, unspecified
378.21	Intermittent esotropia, monocular
378.22	Intermittent esotropia, alternating
378.23	Intermittent exotropia, monocular
378.24	Intermittent exotropia, alternating
378.30	Heterotropia, unspecified
378.31	Hypertropia
378.32	Hypotropia
378.33	Cyclotropia
378.34	Monofixation syndrome
378.35	Accommodative component in esotropia
378.40	Heterophoria, unspecified
378.41	Esophoria
378.42	Exophoria
378.43	Vertical heterophoria
378.44	Cyclophoria
378.45	Alternating hyperphoria
378.50	Paralytic strabismus, unspecified
378.51	Third or oculomotor nerve palsy, partial
378.52	Third or oculomotor nerve palsy, total
378.53	Fourth or trochlear nerve palsy
378.54	Sixth or abducens nerve palsy
378.55	External ophthalmoplegia
378.56	Total ophthalmoplegia
378.60	Mechanical strabismus
378.61	Brown's (tendon) sheath syndrome
378.62	Mechanical strabismus from other musculofascial disorders
378.63	Limited duction associated with other conditions
378.71	Duane's syndrome
378.72	Progressive external ophthalmoplegia
378.73	Strabismus in other neuromuscular disorders
378.81	Palsy of conjugate gaze
378.82	Spasm of conjugate gaze
378.83	Convergence insufficiency or palsy
378.84	Convergence excess or spasm
378.85	Anomalies of divergence
378.86	Intranuclear ophthalmoplegia
378.87	Other dissociated deviation of eye movements
378.9	Unspecified disorder of eye movements
438.31	Monoplegia of upper limb affecting dominant side
438.32	Monoplegia of upper limb affecting nondominant side
438.41	Monoplegia of lower limb affecting dominant side
438.42	Monoplegia of lower limb affecting nondominant side
478.75	Laryngeal spasm
478.79	Other diseases of larynx, not elsewhere classified
530.0	Achalasia and cardiospasm
565.0	Anal fissure
723.5	Torticollis, unspecified
728.85	Spasm of muscle
729.82	Other musculoskeletal symptoms referable to limbs, cramp
780.8	Generalized hyperhidrosis

Diagnoses that Support Medical Necessity

N/A

ICD-9 Codes that DO NOT Support Medical Necessity

N/A

Diagnoses that DO NOT Support Medical Necessity

N/A

Documentation Requirements

• Documentation supporting the medical necessity for this procedure should be legible, maintained in the patient's medical record, and available to Medicare upon request.
• Appropriate HCPCS codes should be used when reporting this service.
• An appropriate diagnosis code should be submitted on the claim. The patient's medical record should indicate the signs/symptoms supporting the diagnosis, as well as functional impairments.
• Number of units used should accompany the claim.

Utilization Guidelines

· Generally, treatment with Botulinum toxin is not necessary more frequently than every 90 days.

Sources of Information and Basis for Decision

· TrailBlazer Health Enterprises, Inc.

· Medical Policy Committee, CareFirst BlueCross BlueShield, Inc.

Advisory Committee Notes

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from N/A.

Start Date of Comment Period

NA

End Date of Comment Period

NA

Start Date of Notice Period

07/12/2002

Revision History

Number	Date	Change
R2	10/01/2004	Added ICD-9 code 438.31. Revised 780.8 to read “Generalized hyperhidrosis.” Per Transmittal 210,
		CR 3303. Converted from LMRP to LCD format.
R1	7/12/2002	Expanded and unranged ICD-9 Codes, revised Description and Indications
		Section. Converted to approved LMRP format and filled in mandatory fields.

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT www.marylandmedicare.com

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.