Printer Friendly Version
Printer Friendly Version
Printer Friendly Version
S.5.01.491
Botox (onabotulinumtoxinA)
Dysport (abobotulinumtoxinA)
Myobloc (rimabotulinumtoxinB)
Xeomin (incobotulinumtoxinA)
Please perform a search of the State Health Plan Medical Drug Formulary for drugs administered and billed through the medical setting.
Botulinum toxin is a neurotoxic protein produced by the bacterium Clostridium botulinum and related species. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neuromuscular junction and thus causes flaccid paralysis. Infection with the bacterium causes the disease botulism. The toxin is also used commercially in medicine, cosmetics, and research. There are seven distinct serotypes designated as type A, B, C-1, D, E, F, and G. However, in the United States four preparations of botulinum are available, produced by two different strains of bacteria.
Related medical policies -
Upon approval, the Botox medical claim must be filed with the clinically supported ICD-10 diagnosis code in the primary position to be considered medically necessary. See Code Reference section.
The use of samples by an individual will not be considered current or stable therapy for purposes of Medical Policy review.
Botox (onabotulinumtoxinA) is the only covered preparations of botulinum toxin for non-cosmetic indications. Dysport (abobotulinumtoxinA), Myobloc (rimabotulinumtoxinB), and Xeomin (incobotulinumtoxinA) are currently considered not medically necessary, as a formulary alternative is available.
Before consideration of coverage may be made, it should be established that the individual does not have any FDA labeled contraindications to the requested agent and that Botox administration follows applicable state guidelines (see Policy Guidelines section).
Botox may be approved for a clinically supported diagnosis listed below when ALL of the criteria are met for a given indication. If an individual is being treated with Botox for one or more indications, the maximum cumulative dose in a 3-month (12 week) interval should not exceed 400 units for adults or the lower of 8 units/kg or 300 units for pediatrics.
Overactive Bladder
Botox (onabotulinumtoxinA) may be considered medically necessary for the treatment of overactive bladder when ALL of the following criteria are met:
Individual is 18 years of age or older
Individual has documented symptoms of urge urinary incontinence, urgency, and frequency (≥1 urinary urgency incontinence episodes and ≥8 urinations per day);
Individual has had an inadequate response to conservative therapies (e.g., bladder training, pelvic floor muscle exercises, fluid management) for at least 2-months;
Individual has failed (see Policy Guidelines section) or is intolerant to an anticholinergic agent (e.g. oxybutynin, tolterodine, trospium, darifenacin, solifenacin or fesoterodine) AND Myrbetriq (mirabegron);
Maximum dose of 100 units into the detrusor muscle every 12 weeks will not be exceeded.
Length of Approval: 12 months
Urinary Incontinence (neurogenic bladder)
Botox (onabotulinumtoxinA) may be considered medically necessary for the treatment of urinary incontinence (neurogenic bladder) when ALL of the following criteria are met:
Individual is 18 years of age or older;
Individual has documented urinary incontinence with detrusor muscle over-activity associated with neurologic condition (e.g. spinal cord injury, multiple sclerosis) and is either spontaneously voiding or using catheterization;
Individual has failed (see Policy Guidelines section) or is intolerant to an anticholinergic agent (e.g. oxybutynin, tolterodine, trospium, darifenacin, solifenacin or fesoterodine) AND Myrbetriq (mirabegron);
Maximum dose of 200 units into the detrusor muscle every 12 weeks will not be exceeded.
Length of Approval: 12 months
Migraine Prophylaxis
Botox (onabotulinumtoxinA) may be considered medically necessary for the prevention of migraines when ALL of the following criteria are met:
Individual is 18 years of age or older;
Individual is experiencing ≥15 days per month with headache lasting 4 hours a day or longer;
Individual has failed (see Policy Guidelines section) at least TWO medications from different drug classes indicated for and at generally accepted doses for migraine prophylaxis within the past 24 months:
a. anticonvulsants – divalproex, valproate, topiramate
b. beta blockers – atenolol, metoprolol, nadolol, propanolol, timolol
c. antidepressants – amitriptyline, venlafaxine
4. Individual has been evaluated for and does not have medication overuse headache;
5. Secondary migraine as a result of an underlying condition or different etiology (e.g., hypertension, stress/anxiety, insomnia, environmental factors) has been ruled out;
6. Botox will not be used in conjunction with a CGRP for prophylactic treatment. There is limited data regarding concomitant use of Botox with CGRP therapy at this time;
7. Maximum dose of 155 units divided in 31 sites every 12 weeks will not be exceeded.
Length of Approval: 12 months
Approved Muscles for Migraine Prophylaxis | Approved Units |
Frontalis | 20 units divided in 4 sites (10 U each side) |
Corrugator | 10 units divided in 2 sites (5 U each side) |
Procerus | 5 units in 1 site |
Occipitalis | 30 units divided in 6 sites (15 U each side) |
Temporalis | 40 units divided in 8 sites (20 U each side) |
Trapezius | 30 units divided in 6 sites (15 U each side) |
Cervical Paraspinal Muscle Group | 20 units divided in 4 sites (10 U each side) |
Spasticity
Botox (onabotulinumtoxinA) may be considered medically necessary for the treatment of spasticity when ALL of the following criteria are met:
Individual is 2 years of age or older;
Individual has had an inadequate response to physical/occupational therapy and/or bracing/splinting;
Individual has failed (see Policy Guidelines section) at least ONE conventional agent (e.g. benzodiazepines, oral or intrathecal baclofen);
ONE of the following:
a. Adults: Maximum dose of 400 units (no more than 50 units per site) every 12 weeks will not be exceeded
b. Pediatrics:
i. Upper Limb: Maximum dose of 6 units/kg or 200 units, whichever is lower, every 12 weeks.
ii. Lower Limb: Maximum dose of 8 units/kg or 300 units, whichever is lower, every 12 weeks.
iii. Both Lower Limbs OR Combination of Upper and Lower Limbs: Maximum dose 10 units/kg body weight or 340 units, whichever is lower, every 12 weeks.
Length of Approval: 12 months
Approved Muscles for Adult Upper Limb Spasticity | Approved Units |
Biceps Brachii | 100 - 200 Units divided in 4 sites |
Flexor Carpi Radialis | 12.5 - 50 Units in 1 site |
Flexor Carpi Ulnaris | 12.5 - 50 Units in 1 site |
Flexor Digitorum Profundus | 30 - 50 Units in 1 site |
Flexor Digitorum Sublimis (Superficialis) | 30 - 50 Units in 1 site |
Adductor Pollicis | 20 Units in 1 site |
Flexor Pollicis Longus | 20 Units in 1 site |
Approved Muscles for Adult Lower Limb Spasticity | Approved Units |
Gastrocnemius medial head | 75 Units divided in 3 sites |
Gastrocnemius lateral head | 75 Units divided in 3 sites |
Soleus | 75 Units divided in 3 sites |
Tibialis Posterior | 75 Units divided in 3 sites |
Flexor hallucis longus | 50 Units divided in 2 sites |
Flexor digitorum longus | 50 Units divided in 2 sites |
Approved Muscles for Pediatric Upper Limb Spasticity | Approved Units |
Biceps Brachii | 1.5 units/kg – 3 units/kg divided in 4 sites |
Brachialis | 1 unit/kg – 2 units/kg divided in 2 sites |
Brachioradialis | 0.5 unit/kg -1 unit/kg divided in 2 sites |
Flexor Carpi Radialis | 0.5 unit/kg – 1 unit/kg divided in 2 sites |
Flexor Carpi Ulnaris | 0.5 unit/kg – 1 unit/kg divided in 2 sites |
Flexor Digitorum Profundus | 0.5 unit/kg – 1 unit/kg divided in 2 sites |
Flexor Digitorum Sublimis | 0.5 unit/kg – 1 unit/kg divided in 2 sites |
Approved Muscles for Pediatric Lower Limb Spasticity | Approved Units |
Gastrocnemius medial head | 1 unit/kg – 2 units/kg divided in 2 sites |
Gastrocnemius lateral head | 1 unit/kg – 2 units/kg divided in 2 sites |
Soleus | 1 unit/kg – 2 units/kg divided in 2 sites |
Tibialis Posterior | 1 unit/kg – 2 units/kg divided in 2 sites |
Cervical Dystonia (spasmodic torticollis)
Botox (onabotulinumtoxinA) may be considered medically necessary for the treatment of cervical dystonia (spasmodic torticollis) when ALL of the following criteria are met:
Individual is 18 years of age or older;
Individual has documented sustained head tilt or abnormal posturing with limited range of motion in the neck;
Individual has a history of recurrent involuntary contraction of one or more muscles of the neck (e.g. sternocleidomastoid, splenius, trapezius or posterior cervical muscles);
Maximum dose of 400 units every 12 weeks will not be exceeded.
Length of Approval: 12 months
Approved Muscles for Cervical Dystonia | Approved Units |
Splenius Capitis | 15-100 units |
Splenius Cervicis | 20-60 units |
Sternocleidomastoid | 15-100 units |
Scalene Complex | 15 units – 50 units |
Semispinalis Capitis | 30-100 units |
Trapezius | 20-100 units |
Longissimus | 30-100 units |
Levator Scapulae | 20-100 units |
Type of Cervical Dystonia | Approved Muscles |
Torticollis | Contralateral: Sternocleidomastoid, Trapezius (upper), Scalenus anterior Ipsilateral: Splenius capitis, Splenius cervicis, Levator scapulae, Longissimus (capitis/cervicis) |
Laterocollis | Ipsilateral: Levator scapulae, Trapezius (upper), Scalenus complex, Sternocleidomastoid, Splenius capitis, Splenius cervicis, Longissimus (capitis/cervicis) |
Anterocollis | Bilateral: Sternocleidomastoid, Scalenus anterior/medius |
Retrocollis | Bilateral: Levator scapulae, Trapezius (upper), Longissimus (capitis/cervicis), Splenius capitis, Splenius cervicis, Semispinalis capitis |
Primary Axillary Hyperhidrosis
Botox (onabotulinumtoxinA) may be considered medically necessary for the treatment of primary axillary hyperhidrosis when ALL of the following criteria are met:
Individual is 18 years of age or older;
Secondary hyperhidrosis as a result of an underlying condition (e.g., hyperthyroidism) has been ruled out;
Individual has focal, visible, excessive sweating of at least 6 months duration with at least TWO of the following characteristics:
a. Bilateral and relatively symmetric
b. Impairs daily activities
c. Frequency of at least one episode per week
d. Age of onset is less than 25 years
e. Positive family history
f. Cessation of focal sweating during sleeping
4. Individual has failed (see Policy Guidelines section) aluminum chloride 20% solution;
5. The prescriber is, or has consulted with, a dermatologist;
6. Maximum dose of 50 units per axilla evenly distributed in multiple sites (10-15) every 12 weeks will not be exceeded.
Length of Approval: 12 months
Blepharospasm
Botox (onabotulinumtoxinA) may be considered medically necessary for the treatment of blelpharospasm when ALL of the following criteria are met:
Individual is 12 years of age or older;
Individual has documented dystonia, including benign essential blepharospasm and VII nerve disorders;
Maximum dose of 30 units (15 units per eye) every 12 weeks will not be exceeded.
Length of Approval: 12 months
Approved Muscles for Blepharospasm | Approved Units |
Medial pre-tarsal orbicularis oculi (upper lid) | Up to 5 units per eye |
Lateral pre-tarsal orbicularis oculi (upper lid) | Up to 5 units per eye |
Lateral pre-tarsal orbicularis oculi (lower lid) | Up to 5 units per eye |
Strabismus
Botox (onabotulinumtoxinA) may be considered medically necessary for the treatment of strabismus when ALL of the following criteria are met:
Individual is 12 years of age or older;
Individual has had an inadequate response to corrective lenses AND any other additional, individual appropriate, conservative corrective therapies (e.g., exercises, eye patching);
Individual has good vision in both eyes and there is a potential for binocular vision;
Maximum dose of 25 units in any one muscle every 12 weeks will not be exceeded.
Length of Approval: 12 months
Condition | Approved Units and Muscles for Strabismus |
Initial Dosing Regimen | |
Vertical muscles | 1.25 – 2.5 units in any one extraocular muscle |
Horizontal strabismus of <20 prism diopters | 1.25 – 2.5 units in any one extraocular muscle |
Horizontal strabismus of 20-50 prism diopters | 2.5 – 5 units in any one extraocular muscle |
Persistent VI nerve palsy of ≥ 1 month duration | 1.25 – 2.5 units in the medial rectus muscle |
Subsequent Dosing Regimen | |
Subsequent doses for individuals experiencing incomplete paralysis may be increased up to two-fold compared to the previously administered dose. The maximum recommended dose as a single injection for any one muscle is 25 units. |
Spasmodic dysphonia (laryngeal spasm)
Botox (onabotulinumtoxinA) may be considered medically necessary for the treatment of spasmodic dysphonia (laryngeal spasm).
Maximum dose: 20 units every 12 weeks
Length of Approval: 12 months
Renewal Evaluation
Botox (onabotulinumtoxinA) may be approved for RENEWAL when ALL of the following criteria are met:
The individual has been previously approved for the requested agent through the BCBSMS review process and continues to meet all initial criteria;
The individual has documented clinical response/improvement (i.e., decrease in symptom severity and/or frequency) from baseline;
Documentation has been provided to support the requested agent is being administered at the correct dosage into the correct muscles for the indication being treated.
Length of Approval: 12 months
Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary.
Out of State Providers: The criteria for Botox administration by a non-physician practitioner do not apply to out of state providers; however, the medical necessity criteria outlined in the Policy section must be met.
Medical Policy Manual coverage guidelines should not be used in lieu of the Participant's specific benefit plan language outlined in the Mississippi's State and School Employees’ Life and Health Insurance Plan.
Electromyography (EMG) guidance may be used to direct the Botox (onabotulinumtoxinA) injection. If so, EMG guidance is considered an integral part of the procedure and no additional reimbursement for the EMG is warranted.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Participant's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Participant's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Participant, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to the Participant. When applied to the care of an Inpatient, it further means that services for the Participant's medical symptoms or conditions require that the services cannot be safely provided to the Participant as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
BCBSMS may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
Botox Administration by a Non-Physician Practitioner in Mississippi
In accordance with the Mississippi State Board of Medical Licensure and the Mississippi State Board of Nursing, the appropriately prepared non-physician practitioner can administer Botox injections provided that all of the following criteria are met:
The non-physician practitioner is educated and competent in the use of Botox and the procedure being performed. This education and competence must be documented initially and on an ongoing basis;
The collaborative physician is educated in the use of Botox;
The non-physician practitioner's protocol addresses the administration of Botox;
The collaborative physician has examined the patient and documented the patient’s chart approving the use of Botox; and
The non-physician practitioner practices according to the generally accepted standards of practice.
Medication Failure
Medication failure is defined as disease progression at generally accepted doses (for ≥3 months use) as appropriate for the disease state being treated. Dosages below the recommended dose for the specific condition being treated and/or experience of common side effects of medication will not be considered medication failure or lack of response for the purpose of this review.
BCBSMS determines patient medication trial and adherence by a review of pharmacy claims data over the preceding twelve months. Additional information may be requested on a case-by-case basis to allow for proper review. If individual is new to BCBSMS and pharmacy records are needed to confirm medication trials and adherence, it is the responsibility of the individual and/or requesting provider to obtain said records and to submit them to BCBSMS upon request. Medical records from the provider that list previously prescribed medications will not be sufficient to show medication trials or adherence.
07/01/2023: New policy added.
09/01/2023: Code Reference section updated to remove CPT codes 32664 and 64613. CPT codes 31513, 31570, 31571, and 31573 were removed from the Not Medically Necessary Codes table and added to the Medically Necessary Codes table.
07/08/2024: Code Reference section updated to add ICD-10 diagnosis codes G43.E01, G43.E09, G43.E11, G43.E19, G81.10, G83.10, G83.20, and G83.30.
06/03/2025: Policy reviewed by Pharmacy & Therapeutics (P&T) Committee; no changes.
10/01/2025: Code Reference section updated to add new ICD-10 diagnosis codes G35.A, G35.B0, G35.B1, G35.C0, G35.C1, and G35.D.
A. Brashear, MD et al. "Safety and efficacy of NeuroBloc* (botulinum toxin type B) in type A -resistant cervical dystonia," in Neurology 1999; 53:1439-1446
Botox prescribing information. Allergan, Inc. September 2020. Last accessed December 2020.
Blue Cross Blue Shield Association policies # 5.01.05 and # 8.01.19
Blue Cross & Blue Shield Association Technology Evaluation Center 1996: Tab 6
Dysport prescribing information. Galderma Laboratories, L.P. July 2020. Last accessed December 2020.
Elan Pharmaceuticals
Hayes Alert, Volume IV, Number 1 – January 2001
Hayes Alert, Volume V, Number 4 – April 2002
Hayes Alert, Volume V, Number 7 – July 2002
Hayes Alert, Volume V, Number 8 – August 2002
Hayes Medical Technology Directory
M.F. Brin, MD et al. "Safety and efficacy of NeuroBloc* (botulinum toxin type A -resistant cervical dystonias," in Neurology 1999, 53:1431-1438.
Mississippi Board of Nursing
Mississippi State Board of Medical Licensure
MYOBLOC prescribing information. Solstice Neurosciences, LLC. September 2020. Last accessed December 2020.
TEC Vol 19, #3, 2002
Xeomin prescribing information. Merz North America, Inc. October 2020. Last accessed December 2020.
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Medical claims for Botox must be filed with the clinically supported ICD-10 diagnosis code from the table below in the primary position for reimbursement. Any Botox claim filed without a clinically supported diagnosis listed below in the primary position will be considered not medically necessary.
Code Number | Description |
CPT-4 | |
31513 | Laryngoscopy, indirect; with vocal cord injection (Note: If the substance injected is not Botulinum Toxin this procedure will be denied) |
31570 | Laryngoscopy, direct, with injection into vocal cord(s), therapeutic (Note: If the substance injected is not Botulinum Toxin this procedure will be denied) |
31571 | Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope(Do not report code 69990 in conjunction with 31571) (Note: If the substance injected is not Botulinum Toxin this procedure will be denied) |
31573 | Laryngoscopy, flexible with therapeutic injection(s) (eg, chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral (Note: If the substance injected is not Botulinum Toxin this procedure will be denied) |
52287 | Cystourethroscopy, with injection(s) for chemodenervation of the bladder |
53899 | Unlisted procedure, urinary system |
64612 | Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (eg, for blepharospasm, hemifacial spasm) |
64615 | Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine) |
64616 | Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis) |
64617 | Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed |
64642 | Chemodenervation of one extremity; 1-4 muscle(s) |
64643 | Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure) |
64644 | Chemodenervation of one extremity; 5 or more muscles |
64645 | Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure) |
64650 | Chemodenervation of eccrine glands; both axillae |
67345 | Chemodenervation of extraocular muscle |
95873 | Electrical stimulation for guidance in conjunction with chemodenervation (list separately in addition to code for primary procedure) |
95874 | Needle electomyography for guidance in conjunction with chemodenervation (list separately in addition to code for primary procedure) |
HCPCS | |
J0585 | Injection, onabotulinumtoxinA (Botox®), 1 unit |
ICD-10 Procedure | |
ICD-10 Diagnosis | |
G24.3 | Spasmodic torticollis |
G24.5 | Blepharospasm |
G35, G35.A, G35.B0, G35.B1, G35.C0, G35.C1, G35.D | Multiple sclerosis (G35.A, G35.B0, G35.B1, G35.C0, G35.C1, G35.D New 10/01/2025) (G35 Deleted 09/30/2025) |
G43.701, G43.709 | Chronic migraine without aura, not intractable |
G43.711, G43.719 | Chronic migraine without aura, intractable |
G43.E01, G43.E09 | Chronic migraine with aura, not intractable |
G43.E11, G43.E19 | Chronic migraine with aura, intractable |
G80.0, G80.1, G80.2, G80.8, G80.9 | Cerebral palsy |
G81.10,G81.11, G81.12, G81.13, G81.14 | Spastic hemiplegia |
G82.20, G82.21, G82.22 | Paraplegia |
G82.50, G82.51, G82.52, G82.53, G82.54 | Quadriplegia |
G83.0 | Diplegia of upper limbs |
G83.10,G83.11, G83.12, G83.13, G83.14 | Monoplegia of lower limb |
G83.20,G83.21, G83.22, G83.23, G83.24 | Monoplegia of upper limb |
G83.30,G83.31, G83.32, G83.33, G83.34 | Monoplegia, unspecified |
G83.81 | Brown-Séquard syndrome |
G83.82 | Anterior cord syndrome |
G83.89 | Other specified paralytic syndromes |
G83.9 | Paralytic syndrome, unspecified |
H49.01, H49.02, H49.03 | Third [oculomotor] nerve palsy |
H49.11, H49.12, H49.13 | Fourth [trochlear] nerve palsy |
H49.21, H49.22, H49.23 | Sixth [abducent] nerve palsy |
H49.31, H49.32, H49.33 | Total (external) ophthalmoplegia |
H49.41, H49.42, H49.43 | Progressive external ophthalmoplegia |
H49.881, H49.882, H49.883 | Other paralytic strabismus |
H49.9 | Unspecified paralytic strabismus |
H50.00 | Unspecified esotropia |
H50.011, H50.012 | Monocular esotropia |
H50.021, H50.022 | Monocular esotropia with A pattern |
H50.031, H50.032 | Monocular esotropia with V pattern |
H50.041, H50.042 | Monocular esotropia with other noncomitancies |
H50.05 | Alternating esotropia |
H50.06 | Alternating esotropia with A pattern |
H50.07 | Alternating esotropia with V pattern |
H50.08 | Alternating esotropia with other noncomitancies |
H50.10 | Unspecified exotropia |
H50.111, H50.112 | Monocular exotropia |
H50.121, H50.122 | Monocular exotropia with A pattern |
H50.131, H50.132 | Monocular exotropia with V pattern |
H50.141, H50.142 | Monocular exotropia with other noncomitancies |
H50.15 | Alternating exotropia |
H50.16 | Alternating exotropia with A pattern |
H50.17 | Alternating exotropia with V pattern |
H50.18 | Alternating exotropia with other noncomitancies |
H50.21, H50.22 | Vertical strabismus |
H50.30 | Unspecified intermittent heterotropia |
H50.311, H50.312 | Intermittent monocular esotropia |
H50.32 | Intermittent alternating esotropia |
H50.331, H50.332 | Intermittent monocular exotropia |
H50.34 | Intermittent alternating exotropia |
H50.40 | Unspecified heterotropia |
H50.411, H50.412 | Cyclotropia |
H50.42 | Monofixation syndrome |
H50.43 | Accommodative component in esotropia |
H50.50, H50.51, H50.52, H50.53, H50.54, H50.55 | Heterophoria |
H50.60 | Mechanical strabismus, unspecified |
H50.611, H50.612 | Brown's sheath syndrome |
H50.69 | Other mechanical strabismus |
H50.811, H50.812 | Duane's syndrome |
H50.89 | Other specified strabismus |
H50.9 | Unspecified strabismus |
H51.0 | Palsy (spasm) of conjugate gaze |
H51.11, H51.12 | Convergence insufficiency and excess |
H51.21, H51.22, H51.23 | Internuclear ophthalmoplegia |
H51.8 | Other specified disorders of binocular movement |
I69.031, I69.032, I69.033, I69.034 | Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage |
I69.041, I69.042, I69.043, I69.044 | Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage |
I69.051, I69.052, I69.053, I69.054 | Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage |
I69.061, I69.062, I69.063, I69.064, I69.065 | Other paralytic syndrome following nontraumatic subarachnoid hemorrhage |
I69.131, I69.132, I69.133, I69.134 | Monoplegia of upper limb following nontraumatic intracerebral hemorrhage |
I69.141, I69.142, I69.143, I69.144 | Monoplegia of lower limb following nontraumatic intracerebral hemorrhage |
I69.151, I69.152, I69.153, I69.154 | Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage |
I69.161, I69.162, I69.163, I69.164, I69.165 | Other paralytic syndrome following nontraumatic intracerebral hemorrhage |
I69.231, I69.232, I69.233, I69.234 | Monoplegia of upper limb following other nontraumatic intracranial hemorrhage |
I69.241, I69.242, I69.243, I69.244 | Monoplegia of lower limb following other nontraumatic intracranial hemorrhage |
I69.251, I69.252, I69.253, I69.254 | Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage |
I69.261, I69.262, I69.263, I69.264, I69.265 | Other paralytic syndrome following other nontraumatic intracranial hemorrhage |
I69.331, I69.332, I69.333, I69.334 | Monoplegia of upper limb following cerebral infarction |
I69.341, I69.342, I69.343, I69.344 | Monoplegia of lower limb following cerebral infarction |
I69.351, I69.352, I69.353, I69.354 | Hemiplegia and hemiparesis following cerebral infarction |
I69.361, I69.362, I69.363, I69.364, I69.365 | Other paralytic syndrome following cerebral infarction |
I69.831, I69.832, I69.833, I69.834 | Monoplegia of upper limb following other cerebrovascular disease |
I69.841, I69.842, I69.843, I69.844 | Monoplegia of lower limb following other cerebrovascular disease |
I69.851, I69.852, I69.853, I69.854 | Hemiplegia and hemiparesis following other cerebrovascular disease |
I69.861, I69.862, I69.863, I69.864, I69.865 | Other paralytic syndrome following other cerebrovascular disease |
I69.931, I69.932, I69.933, I69.934 | Monoplegia of upper limb following unspecified cerebrovascular disease |
I69.941, I69.942, I69.943, I69.944 | Monoplegia of lower limb following unspecified cerebrovascular disease |
I69.951, I69.952, I69.953, I69.954 | Hemiplegia and hemiparesis following unspecified cerebrovascular disease |
I69.961, I69.962, I69.963, I69.964, I69.965 | Other paralytic syndrome following unspecified cerebrovascular disease |
J38.5 | Laryngeal spasm (specific to State Health Plan as exception) |
L74.510 | Primary focal hyperhidrosis, axilla |
N31.9 | Neuromuscular dysfunction of bladder, unspecified |
N32.81 | Overactive bladder |
N39.41 | Urge incontinence |
N39.46 | Mixed incontinence |
R49.0 | Dysphonia (specific to State Health Plan as exception) |
S06.2X0S | Diffuse traumatic brain injury without loss of consciousness, sequela |
S06.2X1S | Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, sequela |
S06.2X2S | Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, sequela |
S06.2X3S | Diffuse traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela |
S06.2X4S | Diffuse traumatic brain injury with loss of consciousness of 6 hours to 24 hours, sequela |
S06.2X5S | Diffuse traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious levels, sequela |
S06.2X9S | Diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela |
S06.300S | Unspecified focal traumatic brain injury without loss of consciousness, sequela |
S06.301S | Unspecified focal traumatic brain injury with loss of consciousness of 30 minutes or less, sequela |
S06.302S | Unspecified focal traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, sequela |
S06.303S | Unspecified focal traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela |
S06.304S | Unspecified focal traumatic brain injury with loss of consciousness of 6 hours to 24 hours, sequela |
S06.305S | Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela |
S06.309S | Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, sequela |
S06.310S | Contusion and laceration of right cerebrum without loss of consciousness, sequela |
S06.311S | Contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less, sequela |
S06.312S | Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela |
S06.313S | Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela |
S06.314S | Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24 hours, sequela |
S06.315S | Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela |
S06.319S | Contusion and laceration of right cerebrum with loss of consciousness of unspecified duration, sequela |
S06.320S | Contusion and laceration of left cerebrum without loss of consciousness, sequela |
S06.321S | Contusion and laceration of left cerebrum with loss of consciousness of 30 minutes or less, sequela |
S06.322S | Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela |
S06.323S | Contusion and laceration of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela |
S06.324S | Contusion and laceration of left cerebrum with loss of consciousness of 6 hours to 24 hours, sequela |
S06.325S | Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela |
S06.329S | Contusion and laceration of left cerebrum with loss of consciousness of unspecified duration, sequela |
S06.340S | Traumatic hemorrhage of right cerebrum without loss of consciousness, sequela |
S06.341S | Traumatic hemorrhage of right cerebrum with loss of consciousness of 30 minutes or less, sequela |
S06.342S | Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela |
S06.343S | Traumatic hemorrhage of right cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, sequela |
S06.344S | Traumatic hemorrhage of right cerebrum with loss of consciousness of 6 hours to 24 hours, sequela |
S06.345S | Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela |
S06.349S | Traumatic hemorrhage of right cerebrum with loss of consciousness of unspecified duration, sequela |
S06.350S | Traumatic hemorrhage of left cerebrum without loss of consciousness, sequela |
S06.351S | Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less, sequela |
S06.352S | Traumatic hemorrhage of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela |
S06.353S | Traumatic hemorrhage of left cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, sequela |
S06.354S | Traumatic hemorrhage of left cerebrum with loss of consciousness of 6 hours to 24 hours, sequela |
S06.355S | Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela |
S06.359S | Traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration, sequela |
S06.4X0S | Epidural hemorrhage without loss of consciousness, sequela |
S06.4X1S | Epidural hemorrhage with loss of consciousness of 30 minutes or less, sequela |
S06.4X2S | Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela |
S06.4X3S | Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela |
S06.4X5S | Epidural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela |
S06.4X9S | Epidural hemorrhage with loss of consciousness of unspecified duration, sequela |
S06.5X0S | Traumatic subdural hemorrhage without loss of consciousness, sequela |
S06.5X1S | Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, sequela |
S06.5X2S | Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela |
S06.5X3S | Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela |
S06.5X4S | Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela |
S06.5X5S | Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela |
S06.5X9S | Traumatic subdural hemorrhage with loss of consciousness of unspecified duration Traumatic subdural hemorrhage NOS, sequela |
S06.6X0S | Traumatic subarachnoid hemorrhage without loss of consciousness, sequela |
S06.6X1S | Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, sequela |
S06.6X2S | Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela |
S06.6X3S | Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela |
S06.6X4S | Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela |
S06.6X5S | Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela |
S06.6X9S | Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, sequela |
S06.9X0S | Unspecified intracranial injury without loss of consciousness, sequela |
S06.9X1S | Unspecified intracranial injury with loss of consciousness of 30 minutes or less, sequela |
S06.9X2S | Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, sequela |
S06.9X3S | Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela |
S06.9X4S | Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, sequela |
S06.9X5S | Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela |
S06.9X9S | Unspecified intracranial injury with loss of consciousness of unspecified duration, sequela |
S14.0XXS | Concussion and edema of cervical spinal cord, sequela |
S14.101S | Unspecified injury at C1 level of cervical spinal cord, sequela |
S14.102S | Unspecified injury at C2 level of cervical spinal cord, sequela |
S14.103S | Unspecified injury at C3 level of cervical spinal cord, sequela |
S14.104S | Unspecified injury at C4 level of cervical spinal cord, sequela |
S14.105S | Unspecified injury at C5 level of cervical spinal cord, sequela |
S14.106S | Unspecified injury at C6 level of cervical spinal cord, sequela |
S14.107S | Unspecified injury at C7 level of cervical spinal cord, sequela |
S14.108S | Unspecified injury at C8 level of cervical spinal cord, sequela |
S14.109S | Unspecified injury at unspecified level of cervical spinal cord |
S14.111S | Complete lesion at C1 level of cervical spinal cord, sequela |
S14.112S | Complete lesion at C2 level of cervical spinal cord, sequela |
S14.113S | Complete lesion at C3 level of cervical spinal cord, sequela |
S14.114S | Complete lesion at C4 level of cervical spinal cord, sequela |
S14.115S | Complete lesion at C5 level of cervical spinal cord, sequela |
S14.116S | Complete lesion at C6 level of cervical spinal cord, sequela |
S14.117S | Complete lesion at C7 level of cervical spinal cord, sequela |
S14.118S | Complete lesion at C8 level of cervical spinal cord, sequela |
S14.119S | Complete lesion at unspecified level of cervical spinal cord, sequela |
S14.121S | Central cord syndrome at C1 level of cervical spinal cord, sequela |
S14.122S | Central cord syndrome at C2 level of cervical spinal cord, sequela |
S14.123S | Central cord syndrome at C3 level of cervical spinal cord, sequela |
S14.124S | Central cord syndrome at C4 level of cervical spinal cord, sequela |
S14.125S | Central cord syndrome at C5 level of cervical spinal cord, sequela |
S14.126S | Central cord syndrome at C6 level of cervical spinal cord, sequela |
S14.127S | Central cord syndrome at C7 level of cervical spinal cord, sequela |
S14.128S | Central cord syndrome at C8 level of cervical spinal cord, sequela |
S14.129S | Central cord syndrome at unspecified level of cervical spinal cord, sequela |
S14.131S | Anterior cord syndrome at C1 level of cervical spinal cord, sequela |
S14.132S | Anterior cord syndrome at C2 level of cervical spinal cord, sequela |
S14.133S | Anterior cord syndrome at C3 level of cervical spinal cord, sequela |
S14.134S | Anterior cord syndrome at C4 level of cervical spinal cord, sequela |
S14.135S | Anterior cord syndrome at C5 level of cervical spinal cord, sequela |
S14.136S | Anterior cord syndrome at C6 level of cervical spinal cord, sequela |
S14.137S | Anterior cord syndrome at C7 level of cervical spinal cord, sequela |
S14.138S | Anterior cord syndrome at C8 level of cervical spinal cord, sequela |
S14.139S | Anterior cord syndrome at unspecified level of cervical spinal cord, sequela |
S14.141S | Brown-Séquard syndrome at C1 level of cervical spinal cord, sequela |
S14.142S | Brown-Séquard syndrome at C2 level of cervical spinal cord, sequela |
S14.143S | Brown-Séquard syndrome at C3 level of cervical spinal cord, sequela |
S14.144S | Brown-Séquard syndrome at C4 level of cervical spinal cord, sequela |
S14.145S | Brown-Séquard syndrome at C5 level of cervical spinal cord, sequela |
S14.146S | Brown-Séquard syndrome at C6 level of cervical spinal cord, sequela |
S14.147S | Brown-Séquard syndrome at C7 level of cervical spinal cord, sequela |
S14.148S | Brown-Séquard syndrome at C8 level of cervical spinal cord, sequela |
S14.149S | Brown-Séquard syndrome at unspecified level of cervical spinal cord, sequela |
S14.151S | Other incomplete lesion at C1 level of cervical spinal cord, sequela |
S14.152S | Other incomplete lesion at C2 level of cervical spinal cord, sequela |
S14.153S | Other incomplete lesion at C3 level of cervical spinal cord, sequela |
S14.154S | Other incomplete lesion at C4 level of cervical spinal cord, sequela |
S14.155S | Other incomplete lesion at C5 level of cervical spinal cord, sequela |
S14.156S | Other incomplete lesion at C6 level of cervical spinal cord, sequela |
S14.157S | Other incomplete lesion at C7 level of cervical spinal cord, sequela |
S14.158S | Other incomplete lesion at C8 level of cervical spinal cord, sequela |
S14.159S | Other incomplete lesion at unspecified level of cervical spinal cord, sequela |
S24.0XXS | Concussion and edema of thoracic spinal cord, sequela |
S24.101S | Unspecified injury at T1 level of thoracic spinal cord, sequela |
S24.102S | Unspecified injury at T2-T6 level of thoracic spinal cord, sequela |
S24.103S | Unspecified injury at T7-T10 level of thoracic spinal cord, sequela |
S24.104S | Unspecified injury at T11-T12 level of thoracic spinal cord, sequela |
S24.109S | Unspecified injury at unspecified level of thoracic spinal cord, sequela |
S24.111S | Complete lesion at T1 level of thoracic spinal cord, sequela |
S24.112S | Complete lesion at T2-T6 level of thoracic spinal cord, sequela |
S24.113S | Complete lesion at T7-T10 level of thoracic spinal cord, sequela |
S24.114S | Complete lesion at T11-T12 level of thoracic spinal cord, sequela |
S24.119S | Complete lesion at unspecified level of thoracic spinal cord, sequela |
S24.131S | Anterior cord syndrome at T1 level of thoracic spinal cord, sequela |
S24.132S | Anterior cord syndrome at T2-T6 level of thoracic spinal cord, sequela |
S24.133S | Anterior cord syndrome at T7-T10 level of thoracic spinal cord, sequela |
S24.134S | Anterior cord syndrome at T11-T12 level of thoracic spinal cord, sequela |
S24.139S | Anterior cord syndrome at unspecified level of thoracic spinal cord, sequela |
S24.141S | Brown-Séquard syndrome at T1 level of thoracic spinal cord, sequela |
S24.142S | Brown-Séquard syndrome at T2-T6 level of thoracic spinal cord, sequela |
S24.143S | Brown-Séquard syndrome at T7-T10 level of thoracic spinal cord, sequela |
S24.144S | Brown-Séquard syndrome at T11-T12 level of thoracic spinal cord, sequela |
S24.149S | Brown-Séquard syndrome at unspecified level of thoracic spinal cord, sequela |
S24.151S | Other incomplete lesion at T1 level of thoracic spinal cord, sequela |
S24.152S | Other incomplete lesion at T2-T6 level of thoracic spinal cord, sequela |
S24.153S | Other incomplete lesion at T7-T10 level of thoracic spinal cord, sequela |
S24.154S | Other incomplete lesion at T11-T12 level of thoracic spinal cord, sequela |
S24.159S | Other incomplete lesion at unspecified level of thoracic spinal cord, sequela |
S34.01XS | Concussion and edema of lumbar spinal cord, sequela |
S34.02XS | Concussion and edema of sacral spinal cord, sequela |
S34.101S | Unspecified injury to L1 level of lumbar spinal cord, sequela |
S34.102S | Unspecified injury to L2 level of lumbar spinal cord, sequela |
S34.103S | Unspecified injury to L3 level of lumbar spinal cord, sequela |
S34.104S | Unspecified injury to L4 level of lumbar spinal cord, sequela |
S34.105S | Unspecified injury to L5 level of lumbar spinal cord, sequela |
S34.109S | Unspecified injury to unspecified level of lumbar spinal cord, sequela |
S34.111S | Complete lesion of L1 level of lumbar spinal cord, sequela |
S34.112S | Complete lesion of L2 level of lumbar spinal cord, sequela |
S34.113S | Complete lesion of L3 level of lumbar spinal cord, sequela |
S34.114S | Complete lesion of L4 level of lumbar spinal cord, sequela |
S34.115S | Complete lesion of L5 level of lumbar spinal cord, sequela |
S34.119S | Complete lesion of unspecified level of lumbar spinal cord, sequela |
S34.121S | Incomplete lesion of L1 level of lumbar spinal cord, sequela |
S34.122S | Incomplete lesion of L2 level of lumbar spinal cord, sequela |
S34.123S | Incomplete lesion of L3 level of lumbar spinal cord, sequela |
S34.124S | Incomplete lesion of L4 level of lumbar spinal cord, sequela |
S34.125S | Incomplete lesion of L5 level of lumbar spinal cord, sequela |
S34.129S | Incomplete lesion of unspecified level of lumbar spinal cord, sequela |
S34.131S | Complete lesion of sacral spinal cord, sequela |
S34.132S | Incomplete lesion of sacral spinal cord, sequela |
S34.139S | Unspecified injury to sacral spinal cord, sequela |
Code Number | Description |
CPT-4 | |
15878 | Suction assisted lipectomy; upper extremity |
43201 | Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance. (Note: If the substance injected is not Botulinum Toxin this procedure will be denied) |
43236 | Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance (Note: If the substance injected is not Botulinum Toxin this procedure will be denied) |
45335 | Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance (Note: If the substance injected is not Botulinum Toxin this procedure will be denied) |
46505 | Chemodenervation of internal anal sphincter |
45381 | Colonoscopy, flexible; with directed submucosal injection(s), any substance (Note: If the substance injected is not Botulinum Toxin this procedure will be denied) |
64646 | Chemodenervation of trunk muscle(s); 1-5 muscle(s) |
64647 | Chemodenervation of trunk muscle(s); 6 or more muscles |
64653 | Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day |
64818 | Sympathectomy, lumbar |
HCPCS | |
J0586 | Injection, abobotulinumtoxinA (Dysport®), 5 units |
J0587 | Injection, rimabotulinumtoxinB (Myobloc®), 100 units |
J0588 | Injection, incobotulinumtoxinA (Xeomin), 1 unit |
ICD-10 Procedure | |
ICD-10 Diagnosis |
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.