G81.11 — Spastic hemiplegia affecting right dominant side
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high 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).
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