We frequently update our articles to reflect the latest changes and updates to Medicare, and strongly recommend you visit this article at link below to confirm you have the latest version.
Printed Date: 9/22/2015
“Chemodenervation” refers to the use of chemical agents to produce neuromuscular blockade for the purpose of selective weakening of specific muscles or muscle groups. Neurotoxins, as well as other chemical agents, are 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 four botulinum neurotoxins available in the US with different FDA-approved indication(s): three distinct serotype A botulinum toxin therapeutic products, onabotulinumtoxinA (BOTOX®), abobotulinumtoxinA (DYSPORT®) and incobotulinumtoxinA (XEOMIN®), and the serotype B botulinum toxin product, rimabotulinumtoxinB (MYOBLOC®). These products are not interchangeable, and 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.
Medicare 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. Botulinum toxin injections are not covered for cosmetic purposes. Palmetto GBA Local Coverage Determination L33458 outlines twelve conditions where chemodenervation techniques may be covered/indicated. The coverage indications are specific and include limitations. Details of coverage indications are available in the L33458 local coverage determination in the reference section included with this article.
Dosage and Frequency
In addition to coverage limitations, there are also dosage and frequency limitations. Chemodenervation treatment has a variable lasting beneficial effect from twelve to sixteen 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.
Legible documentation to support medical necessity must be present for each date of service billed on the claim and should include the following elements:
We value your opinion and want to provide the highest-quality and most relevant Medicare knowledge possible. Please let us know if this article was helpful.
It didn't answer my question
This article was helpful
We’re glad we could help you today and appreciate your feedback. When you rate our articles as most helpful, we know that we are on the right track for providing you with important news and information.
We're sorry this article didn't help you today. We'll use your feedback to review this article try to revise or expand it. In the meantime we recommend you:
Last Updated: 06/16/2020
Applies to: Prior Authorization, JJ Part A, JJ Part B, JM Part A, JM Part B
Article Topics: Appeals, Redeterminations, and PTANs