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OPD Procedure: Botulinum Toxin Injections

To meet Medicare coverage requirements, botulinum toxin injections must be reasonable and medically necessary. For prior authorization purposes, administration code 64612 or 64615 must be paired with one of the 4 medication codes: J0585, J0586, J0587 or J0588. A medication code used in conjunction with any other administration code does not require prior authorization.

Medical Necessity

Services are considered reasonable and medically necessary in patients with the following conditions, which may include, but is not limited to:

  • Certain neuromuscular disorders
  • Dystonias, spasms and twitches
  • Blepharospasms
  • Headaches/migraines ≥ 15 per month lasting 4 or more hours
  • Hemifacial spasms
  • Strabismus

General Documentation Requirements

  • Documentation on dosage and site
  • For type A injections, documentation when electromyography is used
  • For blepharospasms, dystonias, hemifacial, and other similar muscle contraction conditions
    • Clinical evaluations, H&P, progress notes, or office visit notes
    • Documentation related to their pain/condition affecting activities of daily living (ADLs)
    • Documentation related to positioning of the head and/or neck
    • Documentation of conservative treatments tried
    • Eye(s) affected, closure of eyelids, involuntary eye muscle contractions – face, jaw, tongue, etc.
    • For initial treatment of headaches/migrainesCurrent clinical evaluations, H&P, progress notes, or office visit notes
    • Documentation related to conservative treatments tried for at least 3 months and the patient’s responses to those treatments
    • Documentation related to the migraine’s effects on ADLs
    • The number and frequency of headaches which meet clinical indication guidelines
  • For continuous treatment of headaches/migraines
    • Clinical evaluations, H&P, progress notes, or office visit notes 3-6 months prior to the requested date of service, if older than 6 months follow initial treatment requirements
    • Documentation on the effectiveness of at least 2 previous botulinum toxin injections
      • Significant decrease in frequency of headaches/migraines per month – it may take up to 2 treatments before effects can be seen
      • Improvement in ADL functioning

Prior Auth Request Form

Prior Authorization OPD: Botulinum Toxin InjectionPDF

Coverage Criteria and Resources


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