CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A

Prior Authorization Criteria — BOTOX® (onabotulinumtoxinA) / Botulinum toxin

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Prior authorization and medical necessity criteria for onabotulinumtoxinA (BOTOX®) billed under J0585–J0588, describing covered indications by ICD-10 diagnosis for West Virginia Bureau for Medical Services.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyPrior Authorization Criteria — BOTOX® (onabotulinumtoxinA)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2019

Next Review Date

Key ActionObtain prior authorization and document an allowed ICD-10 diagnosis when billing J0585–J0588 for onabotulinumtoxinA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4J‑codes listed

>50ICD-10 codes enumerated

2019-01-01Prior auth effective (CPT 64615)

includes lateralityLaterality specified

Coverage Criteria

Initial therapy

Covered when ALL of the following are met:

Initiation of botulinum toxin: Administration of onabotulinumtoxinA (BOTOX®) is considered medically necessary when given for one of the indications listed in the policy's ICD-10 diagnosis restriction list.

Claims for botulinum toxin must be billed under HCPCS J0585, J0586, J0587, or J0588.

J0585 coverage with diagnosis and CPT pairing requirements

Coverage for J0585 and CPT 52287 is limited to specific diagnoses and billing pairings:

Migraine indication for J0585: When billing HCPCS J0585 for migraine, the claim must list one of the specified intractable migraine ICD-10 codes (examples: G43.011, G43.119, G43.711, G43.719).

Allowed migraine ICD-10 codes are listed in the policy (see migraine ICD-10 restriction).

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyPrior Authorization Criteria — BOTOX® (onabotulinumtoxinA)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2019

Next Review Date

Key ActionObtain prior authorization and document an allowed ICD-10 diagnosis when billing J0585–J0588 for onabotulinumtoxinA.

SourceLink

On This Page

Coding and Billing Codes

Billing HCPCS Codes for BOTOX®HCPCSCovered

J0585	onabotulinumtoxinA, per unit (as listed for billing)
J0586	botulinum toxin (other HCPCS listed)
J0587	botulinum toxin (other HCPCS listed)
J0588	botulinum toxin (other HCPCS listed)

Allowed ICD-10 Diagnoses (partial list)ICD-10

G04.1	Tropical spastic paraplegia
G11.4	Hereditary spastic paraplegia
G24.02	Drug induced acute dystonia
G24.1	Genetic torsion dystonia
G24.3	Spasmodic torticollis
G24.4	Idiopathic orofacial dystonia
G24.5	Blepharospasm
G24.8	Other dystonia
G24.9	Dystonia, unspecified
G25.89	Other specified extrapyramidal and movement disorders

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Ocular and cranial nerve ICD-10 codes (partial)ICD-10

H02.041	Spastic entropion of right upper eyelid
H02.042	Spastic entropion of right lower eyelid
H49.00	Third [oculomotor] nerve palsy, unspecified eye
H49.01	Third [oculomotor] nerve palsy, right eye
H49.02	Third [oculomotor] nerve palsy, left eye
H49.10	Fourth [trochlear] nerve palsy, unspecified eye
H49.20	Sixth [abducent] nerve palsy, unspecified eye
H49.21	Sixth [abducent] nerve palsy, right eye
H49.22	Sixth [abducent] nerve palsy, left eye
H49.23	Sixth [abducent] nerve palsy, bilateral

Covered ICD-10 Diagnosis Codes (strabismus/ophthalmoplegia)ICD-10

H49.20	Sixth [abducent] nerve palsy, unspecified eye
H49.21	Sixth [abducent] nerve palsy, right eye
H49.32	Total (external) ophthalmoplegia, left eye
H49.33	Total (external) ophthalmoplegia, bilateral
H49.40	Progressive external ophthalmoplegia, unspecified eye
H49.41	Progressive external ophthalmoplegia, right eye
H49.42	Progressive external ophthalmoplegia, left eye
H49.43	Progressive external ophthalmoplegia, bilateral
H49.881	Other paralytic strabismus, right eye
H49.882	Other paralytic strabismus, left eye

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Paralytic strabismus / ophthalmoplegia codesICD-10

H49.20	Sixth [abducent] nerve palsy, unspecified eye
H49.21	Sixth [abducent] nerve palsy, right eye
H49.33	Total (external) ophthalmoplegia, bilateral
H49.40	Progressive external ophthalmoplegia, unspecified eye
H49.41	Progressive external ophthalmoplegia, right eye
H49.42	Progressive external ophthalmoplegia, left eye
H49.43	Progressive external ophthalmoplegia, bilateral
H49.881	Other paralytic strabismus, right eye
H49.882	Other paralytic strabismus, left eye
H49.883	Other paralytic strabismus, bilateral

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Esotropia / pattern and noncomitancy codesICD-10

H50.00	Unspecified esotropia
H50.011	Monocular esotropia, right eye
H50.012	Monocular esotropia, left eye
H50.021	Monocular esotropia with A pattern, right eye
H50.022	Monocular esotropia with A pattern, left eye
H50.031	Monocular esotropia with V pattern, right eye
H50.032	Monocular esotropia with V pattern, left eye
H50.041	Monocular esotropia with other noncomitancies, right eye

Listed ICD-10 Codes (H49, H50 series)ICD-10

H49.20	Sixth [abducent] nerve palsy, unspecified eye
H49.21	Sixth [abducent] nerve palsy, right eye
H49.41	Progressive external ophthalmoplegia, right eye
H49.42	Progressive external ophthalmoplegia, left eye
H49.43	Progressive external ophthalmoplegia, bilateral
H49.881	Other paralytic strabismus, right eye
H49.882	Other paralytic strabismus, left eye
H49.883	Other paralytic strabismus, bilateral
H49.889	Other paralytic strabismus, unspecified eye
H49.9	Unspecified paralytic strabismus

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Covered ICD-10 Diagnosis Codes (strabismus/esotropia)ICD-10

H49.20	Sixth [abducent] nerve palsy, unspecified eye
H49.21	Sixth [abducent] nerve palsy, right eye
H49.41	Progressive external ophthalmoplegia, right eye
H49.42	Progressive external ophthalmoplegia, left eye
H49.43	Progressive external ophthalmoplegia, bilateral
H49.881	Other paralytic strabismus, right eye
H49.882	Other paralytic strabismus, left eye
H49.883	Other paralytic strabismus, bilateral
H49.889	Other paralytic strabismus, unspecified eye
H49.9	Unspecified paralytic strabismus

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Covered ICD-10 Codes (diagnoses)ICD-10Covered

H49.20	Sixth [abducent] nerve palsy, unspecified eye
H49.21	Sixth [abducent] nerve palsy, right eye
H49.42	Progressive external ophthalmoplegia, left eye
H49.43	Progressive external ophthalmoplegia, bilateral
H49.881	Other paralytic strabismus, right eye
H49.882	Other paralytic strabismus, left eye
H49.883	Other paralytic strabismus, bilateral
H49.889	Other paralytic strabismus, unspecified eye
H49.9	Unspecified paralytic strabismus
H50.00	Unspecified esotropia

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Listed ICD-10 Diagnosis CodesICD-10

H49.20	Sixth [abducent] nerve palsy, unspecified eye
H49.21	Sixth [abducent] nerve palsy, right eye
H49.42	Progressive external ophthalmoplegia, left eye
H49.43	Progressive external ophthalmoplegia, bilateral
H49.881	Other paralytic strabismus, right eye
H49.882	Other paralytic strabismus, left eye
H49.883	Other paralytic strabismus, bilateral
H49.889	Other paralytic strabismus, unspecified eye
H49.9	Unspecified paralytic strabismus
H50.00	Unspecified esotropia

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Covered ICD-10 Diagnosis Codes for strabismus and paralytic strabismusICD-10

H50.011	Monocular esotropia, right eye
H50.012	Monocular esotropia, left eye
H50.021	Monocular esotropia with A pattern, right eye
H50.022	Monocular esotropia with A pattern, left eye
H50.031	Monocular esotropia with V pattern, right eye
H50.032	Monocular esotropia with V pattern, left eye
H50.041	Monocular esotropia with other noncomitancies, right eye
H50.042	Monocular esotropia with other noncomitancies, left eye
H50.05	Alternating esotropia
H50.06	Alternating esotropia with A pattern

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ICD-10 diagnosis codes for strabismus and paralytic strabismusICD-10

H49.889	Other paralytic strabismus, unspecified eye
H49.9	Unspecified paralytic strabismus
H50.00	Unspecified esotropia
H50.011	Monocular esotropia, right eye
H50.012	Monocular esotropia, left eye
H50.021	Monocular esotropia with A pattern, right eye
H50.022	Monocular esotropia with A pattern, left eye
H50.031	Monocular esotropia with V pattern, right eye
H50.032	Monocular esotropia with V pattern, left eye
H50.041	Monocular esotropia with other noncomitancies, right eye

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Ocular motor / strabismus ICD-10 codes (partial list)ICD-10

H50.07	Alternating esotropia with V pattern
H50.08	Alternating esotropia with other noncomitancies
H50.10	Unspecified exotropia
H50.111	Monocular exotropia, right eye
H50.112	Monocular exotropia, left eye
H49.20	Sixth [abducent] nerve palsy, unspecified eye
H49.21	Sixth [abducent] nerve palsy, right eye
H49.881	Other paralytic strabismus, right eye
H49.882	Other paralytic strabismus, left eye
H49.883	Other paralytic strabismus, bilateral

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Post-cerebrovascular monoplegia ICD-10 codes (partial list)ICD-10

I69.031	Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.032	Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.141	Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right dominant side
I69.341	Monoplegia of lower limb following cerebral infarction affecting right dominant side
I69.931	Monoplegia of upper limb following unspecified cerebrovascular disease affecting right dominant side

Other ICD-10 indications (voice, hyperhidrosis, spasm/contracture)ICD-10

J38.00	Paralysis of vocal cords and larynx, unspecified
J38.01	Paralysis of vocal cords and larynx, unilateral
J38.02	Paralysis of vocal cords and larynx, bilateral
L74.510	Primary focal hyperhidrosis, axilla
M43.6	Torticollis
R49.0	Dysphonia

ICD-10 diagnosis restriction for J0585 when used for migraineICD-10Covered

G43.011	Migraine without aura, intractable, with status migrainosus
G43.019	Migraine without aura, intractable, without status migrainosus
G43.111	Migraine with aura, intractable, with status migrainosus
G43.119	Migraine with aura, intractable, without status migrainosus
G43.711	Chronic migraine without aura, intractable, with status migrainosus
G43.719	Chronic migraine without aura, intractable, without status migrainosus

Bladder/urogenital procedure and HCPCSmixedCovered

CPT 52287	Cystoscopy with injection of agent into bladder (used when billing J0585 for listed bladder diagnoses)
HCPCS J0585	Botox (onabotulinumtoxinA)

CPT chemodenervation codes (prior authorization rules apply)CPT

64615	Chemodenervation injection code (single or multiple muscles; see CPT book)
64616	Chemodenervation of muscle, other (list group)
64617	Chemodenervation of muscle, other (list group)
64642	Chemodenervation code (list)
64643	Chemodenervation code (list)
64644	Chemodenervation code (list)
64645	Chemodenervation code (list)
64646	Chemodenervation code (list)
64647	Chemodenervation code (list)

CPT chemodenervation codes (listed)CPT

64616
64617
64642
64643
64644
64645
64646
64647

Botulinum toxin J-codes referencedHCPCS

J0585
J0586
J0587
J0588

Provider specialty restriction — CPT 64615

RestrictionCPT 64615 limited to providers in Neurology or Neurosurgery (prior authorization required effective Jan 1, 2019).

Effective dateJanuary 1, 2019

Prior authorizationPrior authorization is required for CPT 64615.

Place of service — outpatient hospitals and physician offices

Allowed places of serviceLimited to outpatient hospitals and physician offices when billing chemodenervation codes or J0585–J0588.

Allowed provider specialtiesGeneral surgery, neurosurgery, neurology, physical medicine; orthopedic surgery added effective 8/1/14.

Claim pairing requirement (office/hospital)When billing J0585–J0588 from physician office or hospital, claim must be billed with a 2014 CPT chemodenervation code (e.g., 64616–64647 or 64615 as applicable).

Provider Actions and Billing Guidance

Prior Authorization

Prior authorization required for BOTOX® (J0585–J0588)

Prior authorization is required for BOTOX® (onabotulinumtoxinA) billed under HCPCS J0585, J0586, J0587, or J0588; initiation is medically necessary only when administered for an indication listed in the policy's ICD-10 diagnosis restrictions.

Note

ICD-10 codes for strabismus and paralytic ophthalmoplegia (informational)

The policy lists ICD-10-CM diagnosis codes for strabismus and paralytic ophthalmoplegia (H49.* and H50.* series) — including codes for sixth nerve palsy, progressive external ophthalmoplegia, other paralytic strabismus, unspecified paralytic strabismus, unspecified esotropia, monocular and alternating esotropia, and pattern-specific subcodes.

Documentation Required

Use listed ICD-10 codes on prior authorization and claims

Use the listed H49.* and H50.* ICD-10 diagnosis codes on prior authorization requests and claims related to paralytic strabismus, ophthalmoplegia, esotropia, and sixth (abducent) nerve palsy to support coverage/billing.

Documentation Required

Reference the specific H49/H50 ICD-10 code on prior auth/claims

Prior authorization correspondence and claims should reference the specific ICD-10 diagnosis code from the H49 or H50 series that corresponds to the patient's condition (e.g., H49.21 for sixth nerve palsy, right eye; H50.011 for monocular esotropia, right eye).

Documentation Required

Reference these ICD-10 diagnosis codes for prior authorization

The document provides diagnosis codes that may be used when requesting authorization; include one of the enumerated ICD-10 codes from the policy's lists when submitting requests for services related to strabismus or esotropia.

Documentation Required

ICD-10 diagnosis codes applicable to prior authorization

ICD-10 codes relevant to paralytic strabismus and esotropia (H49.* and H50.* series) are listed and may be used to support prior authorization and claims for related services.

Documentation Required

Diagnosis codes relevant to prior authorization (H49/H50 series)

These chunks contain diagnosis codes (H49.*, H50.*) that may be used as supporting diagnoses for prior authorization requests; ensure the appropriate subcode reflecting laterality/pattern is selected.

Documentation Required

ICD-10 codes (H49, H50) that may support prior authorization

The policy lists H49 and H50 series ICD-10 codes (paralytic strabismus and esotropia) which may be used to support authorization; include the specific listed code when submitting claims or prior authorization requests.

Documentation Required

Use these ICD-10 codes on submissions

Supply the ICD-10 diagnosis codes from the policy's enumerated lists (H49.*, H50.*) on authorization and claim submissions to link the service to an allowed diagnosis.

Prior Authorization

Prior authorization required for CPT 64615 (effective 1/1/2019)

Effective January 1, 2019, prior authorization is required for CPT 64615; billing of CPT 64615 is limited to Neurology or Neurosurgery providers and must be paired with J0585 when billing from physician office or hospital POS as specified.

CPT 64615 requires prior authorization effective 1/1/2019
Limited to Neurology or Neurosurgery
When billing J0585 from physician office or hospital, claim must be billed with CPT 64615

Prior Authorization

Prior authorization for chemodenervation CPTs (64616–64647) when billed with J0585–J0588

As of October 1, 2014, prior authorization is required for CPT codes 64616, 64617, and 64642–64647 when billed with J0585–J0588; when billing these J-codes from physician office or hospital, include one of the listed 2014 CPT chemodenervation codes.

CPTs 64616, 64617, 64642–64647 require prior authorization (effective 10/1/2014)
When billing J0585–J0588 from physician office or hospital, claim must include a 2014 CPT chemodenervation code from the listed group

Prior Authorization

Prior authorization requirement for listed chemodenervation CPTs

Prior authorization is required for CPT codes 64616, 64617, 64642, 64643, 64644, 64645, 64646, and 64647 as of October 1, 2014; claims may be denied if authorization is not obtained.

Note

Step Therapy

No step therapy requirements in this excerpt

No step therapy requirements are specified in the document excerpts provided.

Note

Step Therapy

No step therapy rules specified

No step therapy requirements are specified in these chunks.

Step Therapy

No step therapy rules stated

No step therapy rules are present in the cited sections of this policy.

Note

Documentation Required

Document link between treatment and listed ICD-10 diagnosis

Documentation must support that onabotulinumtoxinA (BOTOX®) is being administered for one of the listed ICD-10 diagnoses in the policy when requesting prior authorization.

Note

Documentation Required

Support laterality and pattern in documentation

Ensure documentation supports the specific ICD-10 subcode used (including laterality and pattern) — for example, indicate 'monocular esotropia with V pattern, right eye' when billing H50.031 to ensure accurate linkage to authorization criteria.

Documentation Required

Use required ICD-10 diagnostic codes from the policy list

When documenting diagnoses related to paralytic strabismus, ophthalmoplegia, and esotropia, use one of the specific ICD-10 codes listed in the policy (examples include H49.20, H49.21, H49.41, H49.42, H49.43, H49.881–H49.889, H49.9, H50.00, H50.011–H50.042).

Note

ICD-10 diagnosis codes provided (no additional documentation specified)

This excerpt lists ICD-10 diagnosis codes for paralytic strabismus and esotropia; it does not add further documentation procedural requirements beyond using the listed codes.

Note

Documentation Required

Provide listed ICD-10 codes on claims/authorizations (no other documentation specified)

The policy provides ICD-10 diagnosis codes (H49.*, H50.*) to support claims or prior authorization requests but does not specify additional documentation elements in these excerpts.

Note

Billing Rule

When billing J0585 for bladder indications, pair with CPT 52287 and allowed ICD-10 code

When billing J0585 for bladder or urogenital indications, the claim must be billed with CPT 52287 and include an allowed ICD-10 diagnosis from the policy's bladder/urogenital list (e.g., G83.4, N31.0, N32.81, N39.41).

J0585 billed from physician office, hospital, or ASC must be billed with CPT 52287 for listed bladder diagnoses
Include one of the allowed bladder/urogenital ICD-10 codes on the claim

Documentation Required

Use specified intractable migraine ICD-10 codes when billing J0585 for migraine

For J0585 used for migraine, the ICD-10 diagnosis must be one of the specified intractable migraine codes listed in the policy (for example, G43.011, G43.119, G43.711, G43.719) to support billing and authorization.

Documentation Required

Ensure provider specialty and place-of-service meet policy limits for chemodenervation

Chemodenervation (the listed CPT codes) is limited to outpatient hospitals and physicians in specified specialties (general surgery, neurosurgery, neurology, physical medicine; orthopedic surgery added effective 8/1/14); ensure provider specialty and place of service meet these limits when requesting authorization or submitting claims.

Limited to outpatient hospitals and physicians
Allowed specialties include general surgery, neurosurgery, neurology, physical medicine (orthopedics added 8/1/14)

Billing Rule

Include a 2014 CPT chemodenervation code with J0585–J0588 on claims

When billing J0585–J0588 from a physician office or hospital, claims must include one of the 2014 CPT chemodenervation procedure codes (64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647) as required by the policy.

Denial Risk

Match J-code billing to an allowed ICD-10 diagnosis to avoid denial

Claims for botulinum toxin must be billed under J0585, J0586, J0587, or J0588 and matched to an allowed ICD-10 diagnosis from the policy's enumerated lists; submissions without an included listed diagnosis risk denial.

Denial Risk

Coding mismatch may trigger denial

Claims or prior authorization requests that do not use one of the listed ICD-10 codes for paralytic strabismus, ophthalmoplegia, esotropia, or sixth nerve palsy may be at risk for coding-related denial if diagnosis coding is required to match coverage criteria.

Denial Risk

Missing or incorrect diagnosis code risks denial

Claims or prior authorization requests lacking an appropriate ICD-10 diagnosis code from the listed H49/H50 series may be at risk for denial.

Note

Denial Risk

Claims for CPT 64615 risk denial without prior authorization

Claims for CPT 64615 submitted without prior authorization (effective January 1, 2019) are at risk for denial.

Denial Risk

Claims with J-codes and listed chemodenervation CPTs require prior authorization

Claims billing J0585–J0588 with chemodenervation CPT codes from the listed group (64616–64647) require prior authorization (effective October 1, 2014) and may be denied if authorization is not obtained.

Billing Rule

Pair J0585 with CPT 52287 for listed bladder diagnoses or risk denial

When billing J0585 for bladder/urogenital indications, the claim must be billed with CPT 52287; failure to pair J0585 with CPT 52287 for the listed bladder diagnoses may result in claim denial.

Billing Rule

Include required 2014 chemodenervation CPT code with J-codes to avoid denial

Claims for J0585–J0588 billed from physician office or hospital must be billed with a 2014 CPT chemodenervation code from the specified list (64616, 64617, 64642–64647); failure to include the required CPT linkage may trigger denial.

Definitions

Botulinum toxin (onabotulinumtoxinA)

DefinitionBotulinum toxin (onabotulinumtoxinA) is an acetylcholine release inhibitor and neuromuscular blocking agent.

Billing HCPCSBOTOX® is billed under HCPCS J0585–J0588.

Medical necessityInitiation meets medical necessity when administered for indications listed in the policy's ICD-10 diagnosis restriction list.

Definition placeholder

PlaceholderNo additional definition provided in this section.

Usage noteRefer to ICD-10 code lists elsewhere in the policy for condition-specific definitions.

RelatedSee chemodenervation and CPT linkage requirements for billing guidance.

Esotropia (H50.*)

DefinitionEsotropia (H50.*): inward deviation of the eye; includes unspecified and laterality/pattern-specific subcodes (e.g., H50.011, H50.031).

Common subtypesMonocular esotropia (H50.011/H50.012), esotropia with A pattern (H50.021/H50.022), V pattern (H50.031/H50.032).

Coding guidanceUse the specific H50.* code that reflects laterality and pattern when submitting prior authorization or claims.

Paralytic strabismus/ophthalmoplegia (H49.*)

DefinitionParalytic strabismus/ophthalmoplegia (H49.*): disorders of extraocular muscle paralysis often due to cranial nerve palsy; codes indicate laterality and specific palsies.

Representative codesIncludes H49.20–H49.43, H49.881–H49.889, and H49.9 to indicate sixth nerve palsy, progressive external ophthalmoplegia, and other paralytic strabismus.

DocumentationSelect the H49.* subcode matching laterality and specific nerve involvement for prior authorization and claims.

Paralytic strabismus / ophthalmoplegia — description

DescriptionParalytic strabismus/ophthalmoplegia describes extraocular muscle dysfunction due to nerve palsy or muscle dysfunction; codes H49.* and H49.881–H49.889 denote side and type.

ExamplesSixth (abducent) nerve palsy: H49.20 (unspecified), H49.21 (right), H49.22 (left); progressive external ophthalmoplegia: H49.40–H49.43.

Billing noteUse specific H49 codes on prior authorization requests and claims to avoid coding-related denials.

Esotropia — forms and H50.* references

FormsEsotropia includes monocular, alternating, A-pattern, V-pattern, and other noncomitant presentations described in the H50.* series.

Representative codesH50.00 (unspecified esotropia), H50.011/H50.012 (monocular right/left), H50.021–H50.032 (A/V patterns), H50.041–H50.042 (other noncomitancies).

Clinical noteDocumentation should support laterality and pattern to match the selected ICD-10 code for authorization.

ICD-10 diagnosis codes for strabismus/esotropia — summary

Included categoriesICD-10 codes in this section cover paralytic strabismus (H49.*), abducent nerve palsy, progressive external ophthalmoplegia, other paralytic strabismus, unspecified paralytic strabismus, and multiple H50.* esotropia subtypes.

Coverage useThese ICD-10 categories are provided to support prior authorization and claims for botulinum toxin treatments for ocular indications.

ActionEnsure the selected ICD-10 code accurately reflects the clinical presentation (laterality/pattern) on submissions.

Diagnosis code list — named conditions

Conditions listedThe diagnosis list names paralytic strabismus, esotropia, exotropia, sixth (abducent) nerve palsy, progressive external ophthalmoplegia, and other ocular motor disorders.

Use in prior authsThese named conditions are intended to be used as supporting diagnoses when requesting authorization for BOTOX® injections.

Not exhaustiveDocument notes this is not an all-inclusive list of indications for botulinum toxin therapy.

Esotropia/Exotropia (H50.*)

DefinitionEsotropia/Exotropia (H50.*): inward (esotropia) and outward (exotropia) deviations of the eye represented within the H50 ICD-10 series.

Representative codesH50.00 (unspecified esotropia), H50.10 (unspecified exotropia), H50.011–H50.042 (monocular/pattern/noncomitant subcodes).

Coding reminderSelect the specific H50 subcode indicating laterality and pattern for claims to align with medical documentation.

Paralytic strabismus / Sixth nerve palsy (H49.*)

DefinitionParalytic strabismus / Sixth nerve palsy (H49.*): cranial nerve palsies affecting extraocular movement are captured in the H49 series.

Representative codesH49.20–H49.23 (sixth nerve palsy unspecified/right/left/bilateral), H49.40–H49.43 (progressive external ophthalmoplegia), H49.881–H49.889 (other paralytic strabismus).

Submission noteUse the most specific H49 code for prior authorization and billing (specify laterality when known).

Strabismus/paralytic strabismus codes — summary

Code list summaryStrabismus and paralytic strabismus codes include H49.* and H50.* subcodes covering monocular/alternating presentations, pattern-specific (A/V), noncomitant variants, and unspecified designations.

ExamplesSee H49.20, H49.21, H50.011, H50.021, H50.031, H50.05 among others listed across the policy's code tables.

Provider actionReference the exact ICD-10 subcode in prior authorization and claims to avoid denials for coding mismatch.

Chemodenervation — definition and allowed settings/providers

DefinitionChemodenervation: injection-based therapeutic use of botulinum toxin to denervate muscles, performed in outpatient hospitals or physician office settings by specified specialties.

Allowed settings/providersLimited to outpatient hospitals and physicians in specialties including general surgery, neurosurgery, neurology, physical medicine; orthopedic surgery added 8/1/14.

Billing linkageClaims for J0585–J0588 billed from physician office or hospital must include an appropriate 2014 CPT chemodenervation code (e.g., 64616–64647 or CPT 64615 where applicable).

2014 CPT chemodenervation codes

Referenced CPT codes (2014)64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647

Billing requirementWhen billing J0585–J0588 from physician office or hospital, claim must be billed with one of the 2014 CPT chemodenervation codes listed.

Prior authorizationAs of October 1, 2014 prior authorization is required for these CPT chemodenervation codes when used with J0585–J0588.

Prior Authorization Criteria — BOTOX® (onabotulinumtoxinA) / Botulinum toxin

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Coverage Criteria

Coding and Billing Codes

Provider Actions and Billing Guidance

Background

Definitions