Skip to Main Content

Print | Bookmark | Font Size: + |

March 19, 2026

Prior Authorization for Botulinum Toxin Injections

CGS recently revised its coverage policy and billing and coding guidance for botulinum toxin injections (BTIs). Please share this information with staff who submit prior authorization requests for services applicable to the:

General Indications and Limitations of Coverage

  • Botulinum toxin dosing must be used in accordance with the United States Food and Drug Administration (FDA) approved labeling.
  • Botulinum toxin must not be administered more frequently than every 12 weeks, regardless of diagnosis, unless specifically addressed in the policy.
  • The use of botulinum toxin for all cosmetic procedures is not a covered benefit under Medicare.
  • When botulinum toxin is used for an approved diagnosis, but the botulinum is also being used with cosmetic intent, the entire claim for the botulinum is not considered reasonable and necessary.
  • BTIs are not considered reasonable and necessary for patients with:
    • A contraindication to botulinum toxin.
    • Existing medical conditions which could affect the neuromuscular function.
    • Hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation of the serotype.
    • Severe clotting disorders.
    • An infection at the injection site.
  • Conservative treatment prior to administration of botulinum toxin must provide:
    • Specific information regarding the conservative treatments which were used; and
    • An objective assessment of the intolerance or inadequacy of the response to the conservative measures.
  • Image guidance is not considered reasonable and necessary.
  • Medicare will allow payment for 1 injection per site regardless of the number of injections made into the site.
    • A site is defined as 1 area.

Resources*

* To find information about a specific disorder being treated, use CTRL+F to search the document.

spacer

26 Century Blvd, Suite NT600, Nashville, TN 37214 © CGS Administrators, LLC. All Rights Reserved