ph-0240
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Myobloc (rimabotulinumtoxinB)

Policy Number: PH-0240

 

Intramuscular/Intradermal

 

Last Review Date: 05/01/2020

Date of Origin: 06/21/2011

Dates Reviewed: 09/2011, 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 02/2013, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 03/2015, 06/2015, 09/2015, 12/2015, 03/2016, 06/2016, 09/2016, 12/2016, 03/2017, 06/2017, 09/2017, 12/2017, 03/2018, 06/2018, 10/2018, 04/2019, 09/2019, 01/2020, 05/2020

  1. Length of Authorization

Coverage will be provided for six months and may be renewed.

  1. Dosing Limits

A.  Quantity Limit (max daily dose) [NDC Unit]:

  • Myobloc 2,500 unit/0.5 mL solution for injection: 1 vial per 84 days
  • Myobloc 5,000 unit/mL solution for injection: 1 vial per 84 days
  • Myobloc 10,000 unit/2 mL solution for injection: 1 vial per 84 days

B.  Max Units (per dose and over time) [HCPCS Unit]:

    Cervical Dystonia

  • 100 billable units per 12 weeks (84 days)

      Upper Limb Spasticity

  • 150 billable units per 12 weeks (84 days)

    Chronic Migraine Prophylaxis

  • 100 billable units per 12 weeks (84 days)

      Chronic Sialorrhea

  • 50 billable units per 12 weeks (84 days)

    Severe Primary Axillary Hyperhidrosis

  • 100 billable units per 12 weeks (84 days)
  1. Initial Approval Criteria 1-26

Coverage is provided in the following conditions:

  • Patient aged 18 years or greater; AND

Universal Criteria

  • Patient does not have a hypersensitivity to any botulinum toxin product; AND
  • Patient does not have an active infection at the proposed injection site; AND
  • Patient evaluated for any disorders which may contribute to respiratory or swallowing difficulty; AND
  • Patient is not on concurrent treatment with another botulinum toxin (i.e., abobotulinumtoxinA, incobotulinumtoxinA, onabotulinumtoxinA, etc.); AND  

Cervical Dystonia 1,2Ф

  • Patient has a history of recurrent involuntary contraction of one or more muscles in the neck; AND
    • Patient has sustained head tilt; OR
    • Patient has abnormal posturing with limited range of motion in the neck

Patient must have failed or have a contraindication or intolerance to incobotulintoxinA (Xeomin) AND abobotulinumtoxinA (Dysport)

Chronic Sialorrhea 1,13,14,15,16,17,18

  • Patient has a history of troublesome sialorrhea for at least a 3-month period

Patient must have failed or have a contraindication or intolerance to incobotulintoxinA (Xeomin)

Upper Limb Spasticity 2,3,4,5,6

Patient must have failed or have a contraindication or intolerance to:

  • One or more conventional agents (i.e., benzodiazepine, oral or intrathecal baclofen, etc.); AND
  • Both incobotulintoxinA (Xeomin) AND abobotulinumtoxinA (Dysport)

Prophylaxis for Chronic Migraines 7,8,9,10,19,20,21,22,24

  • Not used in combination with calcitonin gene-related peptide (CGRP) inhibitors (e.g., eptinezumab, erenumab, galcanezumab, fremanezumab, etc.); AND
  • Patient is utilizing prophylactic intervention modalities (i.e. pharmacotherapy, behavioral therapy, or physical therapy, etc.); AND
  • Patient has 15 or more headache (tension-type-like and/or migraine-like) days per month for at least 3 months; AND
    • Patient has had at least five attacks with features consistent with migraine (with and/or without aura)§; AND
        •  
    • On at least 8 days per month for at least 3 months:
  • Headaches have characteristics and symptoms consistent with migraine§; OR
  • Patient suspected migraines are relieved by a triptan or ergot derivative medication; AND
        • Patient has failed at least an 8-week trial of any two oral medications for the prevention of migraines (see list of migraine-prophylactic medications below for examples)

Severe Primary Axillary Hyperhidrosis 1,11,12,25,26

  • Patient has tried and failed ≥ 1 month trial of a topical agent (e.g., aluminum chloride, glycopyrronium, etc.); AND
    • Patient has a history of medical complications such as skin infections or significant functional impairments; OR
    • Patient has had a significant burden of disease or impact to activities of daily living due to condition (e.g., impairment in work performance/productivity, frequent change of clothing, difficulty in relationships and/or social gatherings, etc.)

FDA approved indication(s); Literature Supported Indication; Ф Orphan Drug

Migraine-Prophylaxis Oral Medications (list not all-inclusive)

  • Antidepressants (e.g., amitriptyline, fluoxetine, nortriptyline, etc.)
  • Beta blockers (e.g., propranolol, metoprolol, nadolol, timolol, atenolol, pindolol, etc.)
  • Angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (ex. lisinopril, candesartan, etc.)
  • Anti-epileptics (e.g., divalproex, valproate, topiramate, etc.)
  • Calcium channels blockers (e.g., verapamil, etc.)

Migraine Features §

Migraine without aura

  • At least five attacks have the following:
  • Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
  • Headache has at least two of the following characteristics:
    • Unilateral location
    • Pulsating quality
    • Moderate or severe pain intensity
    • Aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs); AND
  • During headache at least one of the following:
  • Nausea and/or vomiting
  • Photophobia and phonophobia

Migraine with aura

  • At least two attacks have the following:
  • One or more of the following fully reversible aura symptoms:
    • Visual
    • Sensory
    • Speech and/or language
    • Motor
    • Brainstem
    • Retinal; AND
  • At least two of the following characteristics:
  • At least one aura symptom spreads gradually over ≥5 minutes, and/or two or more symptoms occur in succession
  • Each individual aura symptom lasts 5 to 60 minutes
  • At least one aura symptom is unilateral
  • The aura is accompanied, or followed within 60 minutes, by headache
  1. Renewal Criteria 1

Coverage can be renewed based upon the following criteria:

  • Patient continues to meet universal and indication specific criteria as identified in section III; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include; symptoms of a toxin spread effect (e.g., asthenia, diplopia, ptosis, dysphagia, dysphonia, dysarthria, breathing difficulties, etc.); AND
  • Disease response as evidenced by the following:

Cervical dystonia

  • Improvement in the severity and frequency of pain; AND
  • Improvement of abnormal head positioning

Patient must have failed or have a contraindication or intolerance to incobotulintoxinA (Xeomin) AND abobotulinumtoxinA (Dysport)

OR There is documentation the patient is currently using the requested agent AND is at risk if therapy is changed.

Upper Limb Spasticity

  • Decrease in tone and/or resistance, of affected areas, based on a validated measuring tool (e.g. Ashworth Scale, Physician Global Assessment, Clinical Global Impression (CGI), etc.)

Patient must have failed or have a contraindication or intolerance to:

  • One or more conventional agents (i.e., benzodiazepine, oral or intrathecal baclofen, etc.); AND
  • Both incobotulintoxinA (Xeomin) AND abobotulinumtoxinA (Dysport)
  • OR There is documentation the patient is currently using the requested agent AND is at risk if therapy is changed.

Prophylaxis for chronic migraines 20

  • Significant decrease in the number, frequency, and/or intensity of headaches; AND
  • Improvement in function; AND
  • Patient continues to utilize prophylactic intervention modalities (i.e. pharmacotherapy, behavioral therapy, physical therapy, etc.)

Chronic sialorrhea

  • Significant decrease in saliva production

Patient must have failed or have a contraindication or intolerance to incobotulintoxinA (Xeomin)

OR There is documentation the patient is currently using the requested agent AND is at risk if therapy is changed.

Severe primary axillary hyperhidrosis

  • Significant reduction in spontaneous axillary sweat production; AND
  • Patient has a significant improvement in activities of daily living
  1. Dosage/Administration

Indication

Dose

Cervical Dystonia

Initial dose: 2,500 – 5,000 units divided among the affected muscles. 

Re-treatment: 2,500-10,000 units every 12 -16 weeks or longer, as necessary

Upper Limb Spasticity

Up to 15,000 units divided among the affected muscles every 12 weeks

Chronic Migraine Prophylaxis

Up to 8,250 units divided among the affected muscles every 12 weeks

Chronic Sialorrhea

Recommended dose:  1,500 – 3,500 units (500 – 1,500 units per parotid gland and 250 units per submandibular gland) every 12 weeks. 

Maximum dose: 5,000 units divided among the affected muscles every 12 weeks.

Severe Primary Axillary Hyperhidrosis

Up to 4,000 units per axilla every 12 weeks

  1. Billing Code/Availability Information

HCPCS Code:

  • J0587 – Injection, rimabotulinumtoxinB, 100 units; 1 billable unit = 100 units

NDC:

    • Myobloc 2,500 unit/0.5 mL Solution for Injection: 10454-0710-xx
    • Myobloc 5,000 unit/mL Solution for Injection: 10454-0711-xx
    • Myobloc 10,000 unit/ 2mL Solution for Injection: 10454-0712-xx
  1. References
  1. Myobloc [package insert].  South San Francisco, CA; Solstice Neurosciences, Inc.; August 2019.  Accessed April 2020.
  2. Simpson DM, Hallett M, Ashman EJ, et al.  Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache. Report of the Guideline Development Subcommittee of the American Academy of Neurology.  Neurology 2016: 86:1-9
  3. Gracies JM, Bayle N, Goldberg S, Simpson DM. Botulinum toxin type B in the spastic arm: a randomized, double-blind, placebo-controlled, preliminary study. Arch Phys Med 29 Rehabil 2014; 95:1303-1311.
  4. Brashear A, McAfee A, Kuhn E, et al. Botulinum Toxin Type B in Upper-Limb Poststroke Spasticity: A Double-Blind, Placebo-Controlled Trial, Arch Phys Med Rehabil 2004;85:705-9.
  5. Brashear A, McAfee A, Kuhn E, et al. Treatment with botulinum toxin type B for upper-limb spasticity. Arch Phys Med Rehabil 2003; 84:103-7.
  6. Hecht J, Preston L, McPhee S. Effects of botulinum toxin type B on shoulder pain, hypertonia, and function in adults with spastic hemiparesis. Poster presented at the 63rd Annual Assembly of the American Academy of Physical Medicine and Rehabilitation; November 21-24, 2002; Orlando, Florida.
  7. Gwynn, MW, English, JB, Baker, TS. Double-blind, placebo-controlled study of Myobloc (botulinum toxin type B) for preventing chronic headache. Poster presented at 45th Annual Scientific Meeting of the American Headache Society; June 19-22, 2003, Chicago, Illinois.
  8. Lake AE III, Saper JR. Botulinum toxin type B for migraine prophylaxis: a 4-month, open-label, prospective outcome study. Poster presented at the 22nd Annual Scientific Meeting of the American Pain Society; March 20-23, 2003, Chicago, Illinois.
  9. Opida CL. Open-label study of Myobloc (botulinum toxin type B) in the treatment of patients with transformed migraine headaches. Poster presented at the International Conference 2002: Basic and Therapeutic Aspects of Botulinum and Tetanus Toxins; June 8-11, 2002, Hannover, Germany
  10. Alvarez M, Grogan P. Effectiveness of botulinum toxin type-A and type-B in exploding, imploding, and ocular migraine headache. Presented at the 5th World Congress of the World Institute of Pain; March 13-16, 2009, New York, New York.
  11. Dressler D, Saberi FA, Benecke R. Botulinum toxin type B for treatment of axillary hyperhidrosis. J Neuol (2002) 249:1729-1732. DOI 10.1007/s00415-002-0929-4.
  12. Baumann L, Slezinger A, Halem M et al. Pilot study of the safety and efficacy of Myobloc™ (botulinum toxin type B) for treatment of axillary hyperhidrosis. International Journal of Dermatology, 44: 418–424. doi: 10.1111/j.1365-4632.2004.02531.x
  13. Chinnapongse R, Gullo K, Nemeth P, Zhang Y, Griggs L. Safety and Efficacy of Botulinum Toxin Type B for Treatment of Sialorrhea in Parkinson’s Disease: A Prospective Double-Blind Trial. Mov Disord. 2012; 27:219-226.
  14. Lagalla G, Millevolte M, Capecci M, Provinciali L, Ceravolo M. Long Lasting Benefits of botulinum toxin type B in Parkinson’s disease-related drooling. J Neurol. 2009;256:563-567
  15. Costa J, Rocha ML, Ferreira J, Evangelista T, Coelho M, de Carvalho M. Botulinum toxin type-B improves sialorrhea and quality of life in bulbar-onset amyotrophic lateral sclerosis. J Neurol. 2008; 255:545-550.
  16. Guidubaldi A, Fasano A, Ialongo T, Piano C, Pompili M, Masciana R, Siciliani L, Sabatelli M, Bentivoglio A. Botulinum Toxin A versus B in Sialorrhea: A Prospective, Randomized, Double-Blind Crossover Pilot Study in Patients with Amyotrophic Lateral Sclerosis or Parkinson’s Disease. Mov Disord. 2011; 26:313-319.
  17. Basciani M, Di Rienzo F, Fontana A, Copetti M, Pellegrini F, Intiso D. Botulinum toxin type B for Sialorrhea in Children with Cerebral Palsy: a randomized trial comparing three doses. Dev Med & Child Neurol. 2011; 53:559-564.
  18. Wright E. Botulinum toxin type B (Myobloc®) for treatment of pediatric sialorrhea. Poster presented at: 63rd Annual Assembly of the American Academy of Physical Medicine and Rehabilitation; November 21- 24, 2002; Orlando, Florida.
  19. The International Classification of Headache Disorders, 3rd edition (beta version).Headache Classification Committee of the International Headache Society (IHS) Cephalalgia. 2013 Jul;33(9):629-808.
  20. Schwedt TJ. Chronic Migraine. BMJ. 2014;348:g1416.
  21. Modi S, Lowder DM. Medications for migraine prophylaxis. Am Fam Physician. 2006 Jan 1; 73(1):72-8.
  22. Pringheim T, Davenport W, Mackie G, et al. Canadian Headache Society guideline for migraine prophylaxis. Can Jneurol Sci. 2012 Mar; 39(2 Suppl 2):S1-S9.
  23. Glaser DA, Hebert AA, Nast A, et al. Topical glycopyrronium tosylate for the treatment of primary axillary hyperhidrosis: Results from the ATMOS-1 and ATMOS-2 phase 3 randomized controlled trials. J Am Acad Dermatol. 2019;80(1):128. Epub 2018 Jul 10
  24. American Headache Society. The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. Headache. 2019 Jan;59(1):1-18. doi: 10.1111/head.13456. Epub 2018 Dec 10.
  25. Haider A, Solish N. Focal hyperhidrosis: diagnosis and management. CMAJ. 2005;172(1):69-75.
  26. Nawrocki S, Cha J. The Etiology, Diagnosis and Management of Hyperhidrosis: A Comprehensive Review. Part II. Therapeutic Options. J Am Acad Dermatol. 2019 Jan 30. pii: S0190-9622(19)30167-7.
  27. Ondo WG, Hunter C, Moore W. A double-blind placebo-controlled trial of botulinum toxin B for sialorrhea in Parkinson's disease. Neurology. 2004; 62:37-40.
  28. Racette BA, Good L, Sagitto S, Perlmutter JS. Botulinum toxin B reduces sialorrhea in Parkinsonism. Mov Disord. 2003; 18:1059-1061.
  29. Jackson CE, Gronseth G, Rosenfeld J, et al. Randomized double-blind study of botulinum toxin type B for sialorrhea in ALS patients. Muscle Nerve. 2009;39(2):137
  30. National Government Services, Inc. Local Coverage Article: Billing and Coding: Botulinum Toxins (A52848). Centers for Medicare & Medicaid Services, Inc. Updated on 10/25/2019 with effective date 10/31/2019. Accessed April 2020.
  31. Noridian Administrative Services, LLC Local Coverage Article: Billing and Coding: Botulinum Toxin Types A and B (A57186). Centers for Medicare & Medicaid Services, Inc. Updated on 09/19/2019 with effective date 10/1/2019. Accessed April 2020.
  32. Wisconsin Physicians Service Insurance Corporation. Local Coverage Article:  Billing and Coding: Botulinum Toxin Type A & Type B (A57474). Centers for Medicare & Medicaid Services, Inc.  Updated on 12/17/2019 with effective date 12/26/2019. Accessed April 2020
  33. CGS, Administrators, LLC. Local Coverage Article: Billing and Coding: Billing and Coding for Botulinum Toxins (A56472). Centers for Medicare & Medicaid Services, Inc. Updated on 11/19/2019 with effective date 11/28/2019. Accessed April 2020.
  34. Noridian Healthcare Solutions, LLC. Local Coverage Article: Billing and Coding: Botulinum Toxin Types A and B Policy (A57185). Centers for Medicare & Medicaid Services, Inc. Updated on 09/19/2019 with effective date 10/01/2019. Accessed April 2020.
  35. Palmetto GBA. Local Coverage Article: Billing and Coding: Chemodenervation (A56646). Centers for Medicare & Medicaid Services, Inc. Updated on 10/02/2019 with effective date 10/10/2019. Accessed April 2020.
  36. Palmetto GBA. Local Coverage Article: Billing and Coding: Upper Gastrointestinal Endoscopy and Visualization (A56389). Centers for Medicare & Medicaid Services, Inc. Updated on 10/10/2019 with effective date 10/17/2019. Accessed April 2020.
  37. First Coast Service Options, Inc. Local Coverage Article: Billing and Coding: Botulinum Toxins (A57715). Centers for Medicare & Medicaid Services, Inc. Updated on 11/21/2019 with effective date 10/03/2019. Accessed April 2020.

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

G24.3

Spasmodic torticollis

G25.89

Other specified extrapyramidal and movement disorders

G35

Multiple sclerosis

G37.0

Diffuse sclerosis of central nervous system

G43.709

Chronic migraine without aura, not intractable, without status migrainosus

G43.719

Chronic migraine without aura, intractable, without status migrainosus

G43.701

Chronic migraine without aura, not intractable, with status migrainosus

G43.711

Chronic migraine without aura, intractable, with status migrainosus

G80.0

Spastic quadriplegic cerebral palsy

G80.1

Spastic diplegic cerebral palsy

G80.2

Spastic hemiplegic cerebral palsy

G81.10

Spastic hemiplegia affecting unspecified side

G81.11

Spastic hemiplegia affecting right dominant side

G81.12

Spastic hemiplegia affecting left dominant side

G81.13

Spastic hemiplegia affecting right nondominant side

G81.14

Spastic hemiplegia affecting left nondominant side

G82.53

Quadriplegia, C5-C7, complete

G82.54

Quadriplegia, C5-C7, incomplete

G83.0

Diplegia of upper limbs, Diplegia (Upper), Paralysis of both upper limbs

G83.20

Monoplegia of upper limb affecting unspecified side

G83.21

Monoplegia of upper limb affecting right dominant side

G83.22

Monoplegia of upper limb affecting left dominant side

G83.23

Monoplegia of upper limb affecting right nondominant side

G83.24

Monoplegia of upper limb affecting left nondominant side

I69.031

Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting right dominant side

I69.032

Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting left dominant side

I69.033

Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting right non-dominant side

I69.034

Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side

I69.039

Monoplegia of upper limb following nontraumatic subarachnoid hemorrhage affecting unspecified side

I69.051

Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side

I69.052

Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side

I69.053

Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right non-dominant side

I69.054

Hemiplegia and hemiparesis following nontraumatic

subarachnoid hemorrhage affecting left non-dominant side

I69.059

Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting unspecified side

I69.131

Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right dominant side

I69.132

Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting left dominant side

I69.133

Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting right non-dominant side

I69.134

Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side

I69.139

Monoplegia of upper limb following nontraumatic intracerebral hemorrhage affecting unspecified site

I69.151

Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side

I69.152

Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side

I69.153

Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right non-dominant side

I69.154

Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side

I69.159

Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting unspecified side

I69.231

Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right dominant side

I69.232

Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left dominant side

I69.233

Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side

I69.234

Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side

I69.239

Monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting unspecified site

I69.251

Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side

I69.252

Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left dominant side

I69.253

Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right non-dominant side

I69.254

Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side

I69.259

Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting unspecified side

I69.331

Monoplegia of upper limb following cerebral infarction affecting right dominant side

I69.332

Monoplegia of upper limb following cerebral infarction affecting left dominant side

I69.333

Monoplegia of upper limb following cerebral infarction affecting right non-dominant side

I69.334

Monoplegia of upper limb following cerebral infarction affecting left non-dominant side

I69.339

Monoplegia of upper limb following cerebral infarction affecting unspecified site

I69.351

Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side

I69.352

Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side

I69.353

Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side

I69.354

Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side

I69.359

Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side

I69.831

Monoplegia of upper limb following other cerebrovascular disease affecting right dominant side

I69.832

Monoplegia of upper limb following other cerebrovascular disease affecting left dominant side

I69.833

Monoplegia of upper limb following other cerebrovascular disease affecting right non-dominant side

I69.834

Monoplegia of upper limb following other cerebrovascular disease affecting left non-dominant side

I69.839

Monoplegia of upper limb following other cerebrovascular disease affecting unspecified site

I69.851

Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side

I69.852

Hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side

I69.853

Hemiplegia and hemiparesis following other cerebrovascular disease affecting right non-dominant side

I69.854

Hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side

I69.859

Hemiplegia and hemiparesis following other cerebrovascular disease affecting unspecified side

I69.931

Monoplegia of upper limb following unspecified cerebrovascular disease affecting right dominant side

I69.932

Monoplegia of upper limb following unspecified cerebrovascular disease affecting left dominant side

I69.933

Monoplegia of upper limb following unspecified cerebrovascular disease affecting right non-dominant side

I69.934

Monoplegia of upper limb following unspecified cerebrovascular disease affecting left non-dominant side

I69.939

Monoplegia of upper limb following unspecified cerebrovascular disease affecting unspecified side

I69.951

Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side

I69.952

Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side

I69.953

Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side

I69.954

Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side

I69.959

Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side

K11.7

Disturbances of salivary secretions

L74.510

Primary focal hyperhidrosis, axilla

M43.6

Torticollis

Dual coding requirements:

  • Primary G and M codes require a secondary G or I code in order to be payable

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA):

Jurisdiction(s): 6; K

NCD/LCD/LCA Document (s): A52848

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A52848&bc=gAAAAAAAAAAA  

Jurisdiction(s): 5, 8

NCD/LCD/LCA Document (s): A57474

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A57474&bc=gAAAAAAAAAAA  

Jurisdiction(s): 9; N

NCD/LCD/LCA Document (s): A57715

https://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=A57715&bc=gAAAAAAAAAAA&

Jurisdiction(s): 15

NCD/LCD/LCA Document (s): A56472

https://www.cms.gov/medicare-coverage-database/search/lcd-date-search.aspx?DocID=A56472&bc=gAAAAAAAAAAAAA==

Jurisdiction(s): F

NCD/LCD/LCA Document (s): A57186

https://www.cms.gov/medicare-coverage-database/search/lcd-date-search.aspx?DocID=A57186&bc=gAAAAAAAAAAAAA==

Jurisdiction(s): E

NCD/LCD/LCA Document (s): A57185

https://www.cms.gov/medicare-coverage-database/search/lcd-date-search.aspx?DocID=A57185&bc=gAAAAAAAAAAAAA==   

Jurisdiction(s):  J & M

NCD/LCD/LCA Document (s): A56646

https://www.cms.gov/medicare-coverage-database/search/lcd-date-search.aspx?DocID=A56646&bc=gAAAAAAAAAAAAA==

Jurisdiction(s): J & M

NCD/LCD/LCA Document (s): A56389

https://www.cms.gov/medicare-coverage-database/search/lcd-date-search.aspx?DocID=A56389&bc=gAAAAAAAAAAAAA==

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA,HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA, LLC

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA, LLC

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC

 

 

 

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