Billing and Coding: Botulinum Toxin Type A & Type B
A57474
Coverage for botulinum toxin type A and B is determined per LCD L34635; medically necessary uses such as chronic migraine (≥15 headache days/month with ≥8 migraine days) and specific spasticity indications listed in the LCD are covered. EMG guidance (CPT 92265, 95873, 95874) is payable when needed to identify injection sites; cosmetic uses, experimental indications (e.g., irritable colon, biliary dyskinesia, craniofacial wrinkles), patients on aminoglycosides, and treatments exceeding accepted dosages without record justification are not covered. Claims must include a diagnosis code, required documentation of medical necessity, dosage/frequency, injection sites, and proper drug‑discard reporting (JW/JZ modifiers) and may require modifier 25 for separate E/M services.
"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."