H50.641 — Lateral rectus muscle entrapment, right eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claim submission must include an appropriate diagnosis code on every claim for botulinum toxin services.
- Medical record must document medical necessity for the injection, a covered diagnosis, dosage and frequency of injections, and specific injection site(s).
- Documentation must support the medical necessity of EMG/electrical stimulation procedures performed to determine injection sites and include appropriate CPT codes when billed (92265, 95873, 95874).
- Providers must record discarded amounts of single‑use botulinum toxin products in the patient’s medical record and report JW modifier for unused drugs or JZ when no discarded amount exists (effective dates per Medicare rule).
Key Coverage Criteria
- Botulinum toxin injections are covered for treatment of chronic migraine when the medical record documents ≥15 headache days per month, with ≥8 days having migraine features.
- Botulinum toxin may be covered for spastic conditions that are listed as medically necessary in LCD L34635 (Codes That Support Medical Necessity).
- Use of botulinum toxin to reduce antagonistic contraction in chronic paralytic strabismus is covered when given in conjunction with surgical repair.
- EMG or electrical stimulation guidance (CPT 92265, 95873, 95874) is payable when medically necessary to determine proper injection site(s) for botulinum toxin.
- Medicare will pay for discarded amounts of single‑use botulinum toxin products when documentation supports the discarded quantity and the claim includes the JW modifier (or JZ when no discarded amount).
- Electrodiagnostic testing (EMG and/or nerve conduction studies) is indicated for evaluation of suspected carpal tunnel syndrome.
20 Active Policies
L34635 — Botulinum Toxin Type A & Type B
J05
A57478 — Billing and Coding: Nerve Conduction Studies and Electromyography
J05
L34594 — Nerve Conduction Studies and Electromyography
J05
A59808 — Billing and Coding: Botulinum Toxin Injections
J05
A57474
Related Codes
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