Does G35.C1 require prior authorization?

No, G35.C1 does not require prior authorization (low confidence). No active coverage policies found for this code.

Verity

`G35.C1` — Active secondary progressive multiple sclerosis

ICD-10-CM

Prior Authorization

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Documentation Required

Medical record must document medical necessity, relevant history, physical exam, and results of pertinent diagnostic tests supporting botulinum toxin use and must reference the covered diagnosis.
For spastic conditions other than upper/lower-limb spasticity, blepharospasm, hemifacial spasm, cervical dystonia or other focal dystonias, documentation must state unresponsiveness to conventional treatment and include dosage, injection site(s), frequency, EMG necessity (if used), and effectiveness.
Claims must report referring/ordering physician name and NPI when required by the service, and a valid ICD-10-CM code that best describes the treated condition must be present on the claim.
Documentation must show exact drug dosage administered, reason for unavoidable wastage, and amount discarded; split-vial use must document amounts given to each patient and pro rata wastage calculation details.

Key Coverage Criteria

Botulinum toxin injections are covered for limb spasticity, including upper- and lower-limb spasticity, when medically necessary.
Botulinum toxin injections are covered for blepharospasm when medically necessary.
Botulinum toxin injections are covered for hemifacial spasm when medically necessary.
Botulinum toxin injections are covered for cervical dystonia when medically necessary.
Botulinum toxin injections are covered for other focal dystonias when medically necessary.
Electromyography (EMG) guidance for injection needle placement is covered when medically necessary and billed with appropriate CPT codes (e.g., 95873; 95874 when not billed with 95873).

20 Active Policies

A57595 — Billing and Coding: Pelvic Floor Dysfunction: Anorectal Manometry and EMG

J05

A56232 — Billing and Coding: Foot Care

J05

L35486 — Pelvic Floor Dysfunction: Anorectal Manometry and EMG

J05

L37205 — Chemotherapy Drugs and their Adjuncts

J05

L34624

Have a follow-up question?

Ask Verity about documentation requirements, denial risks, or coverage in your state.

When billing discarded drug amounts to Medicare, use -JW modifier on a separate line with appropriate units rounded to the nearest unit such that total billed does not exceed vial contents; effective July 1, 2023 use JZ when no discarded amount.

Providers must maintain documentation of reconstitution and waste and be prepared to supply documentation or peer-reviewed literature upon contractor request for case-by-case determinations.

— Somatosensory Testing

A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

J05

A57597 — Billing and Coding: Somatosensory Testing

J05

L34635 — Botulinum Toxin Type A & Type B

J05

L37015 — Visual Electrophysiology Testing

J05

A57474 — Billing and Coding: Botulinum Toxin Type A & Type B

J05

L34594 — Nerve Conduction Studies and Electromyography

J05

A57478 — Billing and Coding: Nerve Conduction Studies and Electromyography

J05

A57599 — Billing and Coding: Visual Electrophysiology Testing

J05

A57668 — Billing and Coding: Nerve Conduction Studies and Electromyography

J06

A57759 — Billing and Coding: Routine Foot Care and Debridement of Nails

J06

A57060 — Billing and Coding: Visual Electrophysiology Testing

J06

A59101 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars

J06

A59105 — Billing and Coding: Off-Label Use of Intravenous Immune Globulin (IVIG)

J06

A52848 — Billing and Coding: Botulinum Toxins

J06

A56845 — Billing and Coding: Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency

J06

G35.C1 — Active secondary progressive multiple sclerosis