Botulinum toxin

Coverage decision

The department or insurer covers a maximum of two courses of botulinum toxin injections per worker (except for catastrophic injuries) for FDA indications with prior authorization.

Botulinum toxin use and products

Botulinum toxins (BTX) prevent synaptic transmission of acetylcholine resulting in muscle paralysis. BTX injections produce temporary chemical denervation of the muscle resulting in a localized reduction in muscle activity.  They may also inhibit afferent neurotransmitters and sensory pathways. FDA has approved the following botulinum toxin products:

Product Description
Botox® or Botox Cosmetic® Onabotulinumtoxin A
Dysport® Abobotulinumtoxin A
Myobloc® Rimabotulinumtoxin B
Xeomin® Incobotulinumtoxin A

 

Non-covered Indications

The department or insurer will not authorize payment for BTX injections for off-label indications.

Prior Authorization Criteria (First course)

  • Condition is causally related to the industrial injury or occupational disease; AND
  • Condition is an FDA-approved indication of the botulinum toxin product being used; AND
  • The condition has not responded to conservative treatment, such as oral medication and physical therapy; AND
  • The worker has no contraindications that would have a negative effect on effectiveness or safety; AND
  • The worker has no history of severe, distant, or delayed adverse events with any previous botulinum toxin injections; AND
  • BTX injection is a part of an agreed upon treatment plan with clearly stated treatment goals of completing vocational rehabilitation and/or returning to work.

Prior Authorization Criteria (Second course)

After an initial course of injections, the department or insurer may authorize one additional course of injections to be administered at least 90 days after the initial course, but only if the first BTX treatment produced a meaningful, functional response allowing the patient to return to work or engage in vocational rehabilitation. Providers must submit documentation describing the worker’s response to BTX to receive authorization for a subsequent injection.

Catastrophic Injuries

Catastrophic injuries such as spinal cord injury in which significant recovery of physical function is not expected are exempt from the two course limit and the requirement of meaningful improvement in function. A maximum of four courses of injections may be authorized per year, with prior authorization.

Billing Codes

HCPCS Code Description
J0585 Onabotulinumtoxin A, 1 unit (Botox® or Botox Cosmetic®)
J0586 Abobotulinumtoxin A, 5 units (Dysport®)
J0587 Rimabotulinumtoxin B, 100 units (Myobloc®)
J0588

Incobotulinumtoxin A, 1 unit (Xeomin®)

 


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