Local Coverage Determination (LCD)

Chemodenervation

L33458

Expand All | Collapse All

Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B MAC	10112 - MAC B	J - J	Alabama
Palmetto GBA	A and B MAC	10212 - MAC B	J - J	Georgia
Palmetto GBA	A and B MAC	10312 - MAC B	J - J	Tennessee
Palmetto GBA	A and B and HHH MAC	11202 - MAC B	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11302 - MAC B	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11402 - MAC B	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11502 - MAC B	J - M	North Carolina

LCD Information

Document Information

LCD ID
L33458

LCD Title
Chemodenervation

Proposed LCD in Comment Period
N/A

Source Proposed LCD
DL33458

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 05/27/2021

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
01/19/2017

Notice Period End Date
03/06/2017

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(1)(D) states no payment can be made for services that are for research or experimentation.

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §50.4.1 Approved Use of Drug

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §160.1 Induced Lesions of Nerve Tracts

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Chemodenervation refers to the use of chemical agents to produce neuromuscular blockade for the purpose of selective weakening of specific muscles, or muscle groups. This policy applies to the use of neurotoxins, as well as, other chemical agents used for this purpose.

Botulinum toxin, a neurotoxin produced by clostridium botulinum, produces a clinical effect by blocking the release of neurotransmitters, principally acetylcholine, from nerve endings. There are currently 4 botulinum neurotoxins available in the United States (US) with different Federal Drug Administration (FDA)-approved indication(s): 3 distinct serotype A botulinum toxin therapeutic products, onabotulinumtoxinA (BOTOX®), abobotulinumtoxinA (DYSPORT®) and incobotulinumtoxinA (XEOMIN®), and the serotype B botulinum toxin product, rimabotulinumtoxinB (MYOBLOC®).

The FDA-approved labeling for each product states that the potency units of the botulinum toxin products are not interchangeable. Labeling differs from product to product; dosing units are not comparable. It is the physician's responsibility to select the appropriate product and dose in accordance with FDA-approval indications for use, compendia-supported uses, and supported by peer reviewed specific scientific literature.

Chemodenervation techniques are indicated/covered for:

1. Chemodenervation of muscle innervated by the facial nerve in the management of blepharospasm or hemifacial spasm

2. Chemodenervation of cervical spinal muscles in the management of spasmodic torticollis

3. Chemodenervation of extremity muscles in the management of dystonias, cerebral palsy, upper and lower limb spasticity (see Note:) and multiple sclerosis

4. Chemodenervation of extraocular muscles in the management of strabismus

5. Chemodenervation of the lower esophageal sphincter in the management of achalasia

6. Chemodenervation of laryngeal muscles in the treatment of adductor spasmodic dysphonia

7. Chemodenervation of bilateral frontalis, trapezius, temporalis, sternocleidomastoid, and splenius capitis muscles for treatment of chronic tension headache and intractable daily headache

8. Chemodenervation of procerus and bilateral frontalis, corrugator, occipitalis, temporalis, trapezius, and cervical paraspinal muscle group for the prophylaxis of headaches in adult patients with chronic migraine (≥ 15 days per month with headache lasting 4 hours a day or longer)

Note: Onabotulinamtoxin A (BOTOX®), is the only botulinum toxin product that is FDA-approved for the prophylaxis of headaches in adult patients with chronic migraine (≥ 15 days per month with headache lasting 4 hours a day or longer).

9. Chemodenervation of sweat glands for the treatment of severe primary hyperhidrosis that is inadequately managed with topical agents. Severe is defined for this purpose as level 3 (sweating barely tolerable/frequently interferes with daily activity) or level 4 (sweating intolerable/always interferes with daily activities) on the Hyperhidrosis Disease Severity Scale (HDSS).

10. Chemodenervation of the internal anal sphincter for the treatment of chronic anal fissure

11. Chemodenervation of the detrusor urinae muscle for the treatment of over activity associated with a neurologic condition in adults with an inadequate response to anticholinergic treatment and for the treatment of overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and frequency, in adults who have an inadequate response to or are intolerant of an anticholinergic medication

12. Chemodenervation of the parotid and submandibular salivary glands, bilaterally

Limitations

Chemodenervation for the treatment of headaches is limited to patients who experience headaches that may result in permanent cerebral dysfunction, or are intractable because the patient cannot tolerate or does not benefit from standard therapies. Candidates for this treatment are patients with:

1. Intractable migraines (with or without aura)

2. Intractable chronic tension-type headache with moderate to severe pain

3. Chronic daily headaches defined as patients experiencing more than 15 days of headache per month (either migraine or tension-type features)

4. Chronic migraine (≥ 15 days per month with headache lasting 4 hours a day or longer) (for the prophylaxis of headaches - in adult patients only)

Note: Intractable headache is defined as a patient meeting 1 of the following criteria for treatment (applies only to disease states 1-3, listed above):

1. Failed trials of at least 3 preventive pharmacologic migraine therapies (e.g., beta-blockers, anticonvulsants, antidepressants) with or without concomitant behavioral and physical therapies, after titration to maximal tolerated doses or have medical contraindications to common therapies or who cannot tolerate common preventative therapies; or

2. Experience chronic daily headaches or recurrent headaches at least twice per month causing disability lasting 3 or more days per month; or

3. Standard abortive medication is required more than twice per week, or is contraindicated, ineffective or not tolerated.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
	View Letter

Requestor Information

Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code	Description
Please accept the License to see the codes.

Revenue Codes

Code	Description
Please accept the License to see the codes.

ICD-10-CM Codes that Support Medical Necessity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Legible documentation to support medical necessity must be present for each date of service billed on the claim. Documentation should include the following elements:

Specific botulinum toxin used
Dosage of toxin used (including dosage in units per site)
A complete description of the site(s) injected
A covered diagnosis (however, when a form of botulinum toxin is used for an indication that is not supported by FDA-approval and/or compendia support, a physician statement in the medical record stating the reason(s) why the unsupported form was used is also required)
Support of the clinical effectiveness of the injections, noting date of last injection (if applicable)
Support for the medical necessity of electromyography or stimulation guidance procedures if performed.

Utilization Guidelines

Chemodenervation treatment has a variable lasting beneficial effect from 12 to 16 weeks, following which the procedure may need to be repeated. It is appropriate to inject the lowest clinically effective dose at the greatest feasible interval that results in the desired clinical result.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers, and the reason for additional services is not justified by documentation.

Sources of Information
N/A

Bibliography

Assessment: The clinical usefulness of botulinum toxin-A in treating neurologic disorders. Report of the therapeutics and technology assessment subcommittee of the American Academy of Neurol. Neurology. 1990;40(9):1332-6.

Bielamowicz S, Ludlow CL. Effects of botulinum toxin on pathophysiology in spasmodic dysphonia. Ann Otol Rhinol Laryngol. 2000;109(2):194-203.

Binder WJ, Brin MF, Blitzer A, Schoenrock LD, Pogoda JM. Botulinum toxin type A (BOTOX®) for treatment of migraine headaches: An open- label study. Otolaryngol Head Neck Surg. 2000;123(6):669-76.

BOTOX® (onabotulinumtoxinA). Irvine, CA: Allergan Pharmaceuticals Ireland; 2017. Accessed 4/14/21.

Brashear A, Lew MF, Dykstra DD, et al. Safety and efficacy of neurobloc (botulinum toxin type B) in type A- responsive cervical dystonia. Neurol. 1999;53(7):1439-46.

Brin MF, Lew MF, Adler CH, et al. Safety and efficacy of neurobloc (botulinum toxin type B) in type A- resistant cervical dystonia. Neurol. 1999;53(7):1431-8.

Ceballos-Baumann AO. Evidence–based medicine in botulinum toxin therapy for cervical dystonia. J Neurol. 2001;248(Suppl 1):14-20.

Cohen LG, Hallett M, Geller BD, Hochberg F. Treatment of focal dystonias of the hand with botulinum toxin injections. J Neurol, Neurosurg & Psychiatry. 1989;52(3):355-63.

Comella CL, Jankovic J, Brin MF. Use of botulinum toxin type A in the treatment of cervical dystonia. Neurol. 2000;55(12 Suppl 5):S15-21.

Cullis PA, O’Brien CF, Truong DD, Koller M, Villegas TP, Wallace JD. Botulinum toxin type B: An open-label, dose–escalation, safety and preliminary efficacy study in cervical dystonia patients. Adv Neurol. 1998;78:227-30.

DYSPORT® (abobotulinumtoxinA). Fort Worth, TX: Ipsen Biopharm Ltd; 2019. Accessed 4/14/21.

Heckmann M, Ceballos-Baumann AO, Plewig G. Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med. 2001;344(7):488-93.

Jankovic J, Brin MF. Therapeutic uses of botulinum toxin. N Engl J Med. 1991;324(17):1186-94.

Keegan DJ, Geerling G, Lee JP, Blake G, Collin JR, Plant GT. Botulinum toxin treatment for hyperlacrimation secondary to aberrant regenerated seventh nerve palsy or salivary gland transplantation. Br J Ophthalmol. 2002;86(1):43-46.

Kranz G, Shamim EA, Lin PT, Kranz GS, Hallett M. Transcranial magnetic brain stimulation modulates blepharospasm: A randomized controlled study. Neurol. 2010;75(16):1465-1471.

Lew MF, Adornato BT, Duane DD, et al. Botulinum toxin type B: A double-blind, placebo-controlled, safety and efficacy study in cervical dystonia. Neurol. 1997;49(3):701-7.

Lew MF, Brashear A, Factor S. The safety and efficacy of botulinum toxin type B in the treatment of patients with cervical dystonia: Summary of three controlled clinical trials. Neurol. 2000;55(12 Suppl 5):S29-35.

Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR, Albanese A. A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med. 1998;338(4):217-20.

MYOBLOC® (rimabotulinumtoxinB). Louisville, KY: Solstice Neurosciences LLC; 2019. Accessed 4/14/21.

Naumann M, Lowe NJ, Kumar CR, Hamm H. Hyperhidrosis clinical investigators group. Botulinum toxin type A is a safe and effective treatment for axillary hyperhidrosis over 16 months: A prospective study. Arch Dermatol. 2003;139(6):731-6.

Pasricha PJ, Ravich WJ, Hendix TR, Sostre S, Jones B, Kalloo AN. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med. 1995;332(12):774-8.

Silberstein S, Mathew N, Saper J, Jenkins S. Botulinum toxin type A as a migraine preventive treatment. Headache. 2000;40(6):445-50.

Tsui JK, Hayward M, Mak EK, Schulzer M. Botulinum toxin type B in the treatment of cervical dystonia: A pilot study. Neurol. 1995;45(11):2109-10.

XEOMIN® (incobotulinumtoxinA). Frankfurt, Germany: Merz Pharmaceuticals; 2018. Accessed 4/14/21.

Yoshimura DM, Aminoff MJ, Olney RK. Botulinum toxin therapy for limb dystonias. Neurol. 1992;42(3Pt1):627-30.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
05/27/2021	R24	Under *Bibliography* changes were made to citations to reflect AMA citation guidelines.	Provider Education/Guidance
09/10/2020	R23	Under *Coverage Indications, Limitations and/or Medical Necessity* added hyperlinks for FDA indications. Under *Bibliography* added citations and hyperlinks for FDA indications and changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD. The registered mark was inserted where applicable throughout the LCD. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
10/10/2019	R22	This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Title XVIII of the Social Security Act, §1833(e) was removed from the *CMS National Coverage Policy* section of this LCD and placed in the related Billing and Coding: Chemodenervation A56646 article. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
07/04/2019	R21	All coding located in the *Coding Information* section has been moved into the related Billing and Coding: Chemodenervation A56646 article and removed from the LCD. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
10/01/2018	R20	Under *ICD-10 Codes that Support Medical Necessity Group: 3 Paragraph* added HCPCS code J0588. This revision is due to a reconsideration request. Under *ICD-10 Codes that Support Medical Necessity Group: 4 Codes* added ICD-10 codes G51.31, G51.32 and G51.33. Under *ICD-10 Codes that Support Medical Necessity Group: 4 Codes* deleted ICD-10 code G51.3. This revision is due to the 2018 Annual ICD-10 Code Update and is effective on October 1, 2018. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To ICD-10-CM Code Changes Reconsideration Request
07/09/2018	R19	Under *Coverage Indications, Limitations and/or Medical Necessity* deleted the verbiage “Onabotulinumtoxin A (Botox®) is the only botulinum toxin that is FDA approved for lower limb spasticity in adults”. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Reconsideration Request
03/15/2018	R18	Under *CMS National Coverage Policy* deleted the “s” from the cited Internet-Only Manual references X2. Throughout the LCD punctuation was corrected. Under *Coverage Indications, Limitations and/or Medical Necessity #7* corrected the spelling of splenius. Throughout the LCD punctuation was corrected. Under *Bibliography* author initials were added to the author name WJ Binder and the spelling of the author name Heckmann was corrected. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance Typographical Error Other
02/26/2018	R17	The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.	Change in Affiliated Contract Numbers
10/01/2017	R16	Under ICD-10 Codes that Support Medical Necessity Group 2: Codes added ICD-10 codes G12.23, G12.24 and G12.25. These revisions are due to the 2017 Annual ICD-10 Updates. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To ICD-10-CM Code Changes
07/07/2017	R15	Under ICD-10 Codes That Support Medical Necessity Group 8: Paragraph added the * Note related to CPT code 64653. Under *ICD-10 Codes That Support Medical Necessity* *Group 8:* *Codes* added ICD 10 codes H04.211, H04.212, H04.213 and L74.52. Under *Sources of Information and* *Basis for Decision* added Keegan DJ, Geerling G, Lee JP, Blake G, Collin JR, Plant GT. Botulinum toxin treatment for hyperlacrimation secondary to aberrant regenerated seventh nerve palsy or salivary gland transplantation. Br J Ophthalmol. 2002;86(1):43-46.	Provider Education/Guidance Reconsideration Request
06/26/2017	R14	Under *Coverage Indications, Limitations and/or Medical Necessity-Indication 9* revised the verbiage to read “Chemodenervation of sweat glands for the treatment of severe primary hyperhidrosis that is inadequately managed with topical agents. Severe is defined for this purpose as level 3 (sweating barely tolerable/frequently interferes with daily activity) or level 4 (sweating intolerable/always interferes with daily activities) on the Hyperhidrosis Disease Severity Scale (HDSS)”. Under *CPT/HCPCS Codes Group 1: Paragraph* added primary procedure CPT codes 64653 and 64999 to the verbiage “Use CPT codes 95873 and 95874 in addition to the code for the primary procedure CPT codes 64612, 64615, 64616, 64642, 64643, 64644, 64645, 64646, 64647”. Under *Group 1: Codes* added CPT codes 64653 and 64999. Under *Group 8: Paragraph* added CPT codes 64653 and 64999 and added the verbiage “*64999 to billed only with L74.512 and L74.513 with chemodenervation”.	Provider Education/Guidance Reconsideration Request
03/07/2017	R13	Under *Coverage Indications, Limitations and/or Medical Necessity bullet 8, Note and Limitations bullet 4* corrected the verbiage “(= 15 days per month with headache lasting 4 hours a day or longer)” to now read “(≥ 15 days per month with headache lasting 4 hours a day or longer)”.	Typographical Error
03/07/2017	R12	Under *Coverage Indications, Limitations and/or Medical Necessity Note bullet 8, Note and Limitations bullet 4* revised the verbiage “(= 15 days per month with headache lasting 4 hours a day or longer)” to now read “(=15 days per month with headache lasting 4 hours a day or longer)”. Under *Note:* revised the verbiage “Intractable headache is defined as a patient meeting one of the following criteria for treatment” to read “Intractable headache is defined as a patient meeting one of the following criteria for treatment (applies only to disease states 1-3, listed above)”. Under *ICD-10 Codes that Support Medical Necessity Group 7: Codes* removed G83.81 and G83.82 and added these codes to *Group 6: Codes (for 64642-64647)*.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
12/10/2016	R11	Under *CMS National Coverage Policy* revised “Manuals” to now read “Manual”. Under *CPT/HCPCS Codes Group 6: Codes* added G83.81 and G83.82 effective for claims for dates of service beginning 09/29/2016. Under *CPT/HCPCS Codes Group 7: Codes* deleted G83.81 and G83.82 as these codes were moved to Group 6 for chemodenervation of the extremity or trunk.	Provider Education/Guidance Other
09/29/2016	R10	Under *Coverage Indications, Limitations and/or Medical Necessity* bullet 3 revised the verbiage to read “Chemodenervation of extremity muscles in the management of dystonias, cerebral palsy, upper and lower limb spasticity (see Note: ) and multiple sclerosis”. Under Note: added the verbiage “Onabotulinumtoxin A (Botox®) is the only botulinum toxin that is FDA approved for lower limb spasticity in adults” to the end of the sentence. Under *ICD-10 Codes that Support Medical Necessity Group 7: Codes* added ICD-10 Codes G83.81 and G83.82.	Provider Education/Guidance Reconsideration Request Revisions Due To ICD-10-CM Code Changes
09/01/2016	R9	Under *CPT/HCPCS Codes Group 1: Paragraph* in the second sentence deleted CPT codes 64611 and 64617. The verbiage was corrected to now read “Use CPT codes 95873 and 95874 in addition to the code for the primary procedure CPT codes 64612, 64615, 64616, 64642, 64643, 64644, 64645, 64646, and 64647”effective on or after October 01, 2015.	Provider Education/Guidance Revisions Due To CPT/HCPCS Code Changes
07/05/2016	R8	Under *CPT/HCPCS Codes Group 1: Paragraph* added verbiage related to achalasia. Under *CPT/HCPCS Codes Group 1: Codes* deleted CPT code 43201. Under *ICD-10 Codes that Support Medical Necessity* deleted *Group 1: Paragraph* stating CPT code 43201; HCPCS codes J0585, J0586, J0587, J0588 and *Group 1: Codes* including ICD-10 code K22.0.	Provider Education/Guidance Revisions Due To CPT/HCPCS Code Changes Revisions Due To ICD-10-CM Code Changes
01/22/2016	R7	Under Coverage Indications, Limitations and/or Medical Necessity under #3 added “upper limb spasticity”; under #8 added “NOTE: Onabotulinamtoxin A (BOTOX®), is the only botulinum toxin product that is FDA-approved for the prophylaxis of headaches in adult patients with chronic migraines (= 15 days per month with headache lasting 4 hours a day or longer)” which was moved from the Utilization Section* of this policy. Under Limitations made a few grammatical changes; changes the word “they” in the first paragraph to read the patient and added “NOTE:” in front of Intractable headache is defined….. Under Associated Information* in the Utilization Guidelines removed the “Onabotulinamtoxin A (BOTOX®), is the only botulinum toxin product that is FDA-approved for the prophylaxis of headaches in adult patients with chronic migraines (≥ 15 days per month with headache lasting 4 hours a day or longer)” as stated above.	Provider Education/Guidance Public Education/Guidance Typographical Error Other (Annual Validation)
12/16/2015	R6	Under *ICD-10 Codes that Support Medical Necessity* added ICD-10 codes I69.051, I69.052, I69.053, I69.054, I69.151, I69.152, I69.153, I69.154, I69.251, I69.252, I69.253, I69.254, I69.351, I69.352, I69.353, I69.354, I69.851, I69.852, I69.853, I69.854, I69.951, I69.952, I69.953, I69.954 to Group 7 as the drug Dysport (abobotulinumtoxinA) HCPCS code J0585 was also approved for the treatment of upper limb spasticity in adult patients, to decrease the severity of increased muscle tone in elbow flexors, wrist flexors and finger flexors by the FDA.	Provider Education/Guidance Automated Edits to Enforce Reasonable & Necessary Requirements Reconsideration Request Revisions Due To ICD-10-CM Code Changes
10/01/2015	R5	Under CMS National Coverage Policy revised Section of Pub 100-2 of CMS Internet-Only Manuals to now read 50.4.1.	Provider Education/Guidance Other (Maintenance Annual Validation)
10/01/2015	R4	Under CPT/HCPCS Codes the following codes have had descriptor changes for CPT codes 64644, 64645, 64647. The change was due to the Annual HCPCS Update, CR 8975, dated 10/24/2014.	Provider Education/Guidance Automated Edits to Enforce Reasonable & Necessary Requirements Revisions Due To CPT/HCPCS Code Changes
10/01/2015	R3	Under CPT/HCPCS Codes section descriptor changes were made to CPT Codes 64644, 64645 and 64647, effective 7/1/2014.	Provider Education/Guidance Revisions Due To CPT/HCPCS Code Changes
10/01/2015	R2	Under ICD-10 Codes that Support Medical Necessity added the following ICD-10 codes to Group 8: G43.011, G43.019, G43.111, G43.119, G43.411, G43.419, G43.511, G43.519, G43.611, G43.619, G43.811, G43.819, G43.831, G43.839, G43.911, G43.919, G43.A1, and G43.B1.	Provider Education/Guidance Automated Edits to Enforce Reasonable & Necessary Requirements Reconsideration Request Revisions Due To ICD-10-CM Code Changes
10/01/2015	R1	Under CPT/HCPCS Codes, Group 2, paragraph section, added CPT codes 63611 and 64615 for clarification in LCD. Under Sources of Information and Basis for Decision removed the statement, "The development and coverage guidelines in this policy were based on a review of pertinent medical literature, policies from other Medicare contractors, and discussions with appropriate specialists," as this statement was deemed no longer necessary within the text of the LCD.	Other ( Provider questioning 64611 and 64615 usage in LCD.)

Associated Documents

Attachments
N/A

Related Local Coverage Documents
Articles
A56646 - Billing and Coding: Chemodenervation
A55428 - Response to Comments: Chemodenervation (MCD Archive Site)
LCDs
DL33458 - Chemodenervation (MCD Archive Site)

Updated On	Effective Dates	Status
05/20/2021	05/27/2021 - N/A	Currently in Effect	You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

Chemodenervation

Read the LCD Disclaimer

License Agreements
American Medical Association Current Procedural Terminology
American Dental Association Current Dental Terminology
American Hospital Association NUBC UB-04

Please review the licensing information below and indicate your agreement and acceptance.

License for Use of Current Procedural Terminology (CPT)

End User Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).

You, your employees, and agents are authorized to use CPT only as agreed upon with the AMA internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt http://www.ama-assn.org/go/cpt.

Applicable FARS\DFARS Restrictions Apply to Government Use.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, AMA Plaza, 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of FAR 52.227-14 (December 2007) and/or subject to the restricted rights provisions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS disclaims responsibility for any liability attributable to end user use of the CPT. CMS will not be liable for any claims attributable to any errors, omissions, or other inaccuracies in the information or material contained on this page. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

License For Use of Current Dental Terminology (CDT^TM)

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood, and agreed to all terms and conditions set forth in this agreement.

If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen.

If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org/ http://www.ADA.org/.

Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use.

Organizations who contract with CMS acknowledge that they may have a commercial CDT license with the ADA, and that use of CDT codes as permitted herein for the administration of CMS programs does not extend to any other programs or services the organization may administer and royalties dues for the use of the CDT codes are governed by their commercial license.

ADA DISCLAIMER OF WARRANTIES AND LIABILITIES

CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values, or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.

CMS DISCLAIMER

The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS disclaims responsibility for any liability attributable to end user use of the CDT. CMS will not be liable for any claims attributable to any errors, omissions, or other inaccuracies in the information or material covered by this license. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I Accept". If you do not agree to the terms and conditions, you may not access or use software. Instead, you must click below on the button labeled "I Do Not Accept" and exit from this computer screen.

License For Use of National Uniform Billing Committee (NUBC) UB-04

These materials contain NUBC Official UB-04 Specifications (UB-04 Data), which is copyrighted by the American Hospital Association (AHA).

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN. IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use UB-04 Data only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of UB-04 Data is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this Agreement. You acknowledge that the AHA holds all copyright, trademark, and other rights in UB-04 Data. You shall not remove, alter, or obscure any AHA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including, by way of illustration and not by way of limitation, making copies of UB-04 Data for resale and/or license, transferring copies of UB-04 Data to any party not bound by this agreement, creating any modified or derivative work of UB-04 Data, or making any commercial use of UB-04 Data. License to use UB-04 Data for any use not authorized herein must be obtained through the American Hospital Association, 155 N. Wacker Drive, Suite 400, Chicago, Illinois, 60606. Applications are available at the NUBC website, http://www.nubc.org/ http://www.nubc.org/.
The UB-04 Data included in this product is commercial technical data and/or computer databases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Hospital Association, 155 N. Wacker Drive, Suite 400, Chicago, Illinois 60606. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.
AHA DISCLAIMER OF WARRANTIES AND LIABILITIES. UB-04 Data is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The sole responsibility for the software, including any UB-04 Data and other content contained therein, is with the Medicare/Medicaid Contractor or the CMS; and no endorsement by the AHA is intended or implied. The AHA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The AHA is a third-party beneficiary to this Agreement.
CMS DISCLAIMER. The scope of this license is determined by the AHA, the copyright holder. Any questions pertaining to the license or use of the UB-04 Data should be addressed to the AHA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE UB-04 DATA. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

Submit Feedback/Ask a Question

Chemodenervation

Document Note

Note History

Contractor Information

LCD Information

Document Information

Issue

CMS National Coverage Policy

Coverage Guidance

Proposed Process Information

Coding Information

Bill Type Codes

Please accept the License to see the codes.

Revenue Codes

Please accept the License to see the codes.

CPT/HCPCS Codes

Please accept the License to see the codes.

ICD-10-CM Codes that Support Medical Necessity

Group 1

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Additional ICD-10 Information

General Information

Revision History Information

Associated Documents

Keywords

Page Help for LCD - Chemodenervation (L33458)

Introduction

More information

Tracking Sheet

Printing a Document to PDF

Get email updates

CMS & HHS WEBSITES

HELPFUL LINKS

RSS FEEDS