ph-90241
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Xeomin (incobotulinumtoxinA)

Policy Number: PH-90241

Intramuscular/Intradetrusor/Intradermal

Last Review Date: 05/03/2021

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, 08/2018, 10/2018, 04/2019, 09/2019, 01/2020, 05/2020, 09/2020, 01/2021, 05/2021

FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill.

  1. Length of Authorization
  • Coverage will be provided for six months and may be renewed.
  • Preoperative use in Ventral Hernia may NOT be renewed.
  1. Dosing Limits
  1. Quantity Limit (max daily dose) [NDC Unit]:
  • Xeomin 50 unit Injection: 1 vial per 84 day supply
  • Xeomin 100 unit Injection: 1 vial per 84 day supply (per 112 days for severe primary axillary hyperhidrosis)
  • Xeomin 100 unit Injection: 5 vials once (for Ventral Hernia only)
  • Xeomin 200 unit Injection: 2 vials per 84 day supply
  1. Max Units (per dose and over time) [HCPCS Unit]:

Indication

Billable Units

Per # days

Cervical dystonia

200

84

Blepharospasms

100

84

Upper limb spasticity

400

84

Prophylaxis for chronic migraines

200

84

Incontinence due to neurogenic detrusor overactivity

200

84

Overactive bladder (OAB)

100

84

Severe primary axillary hyperhidrosis

100

112

Sialorrhea

100

112

Ventral Hernia

500

N/A

  1. Initial Approval Criteria1

Coverage is provided in the following conditions:

  • Patient is at least 18 years of age (unless otherwise noted); AND

Universal Criteria 1

  • Patient evaluated for any disorders which may contribute to respiratory or swallowing difficulty; AND
  • 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 is not on concurrent treatment with another botulinum toxin (i.e., abobotulinumtoxinA, onabotulinumtoxinA, rimabotulinumtoxinB, etc.); AND

Cervical Dystonia † 1

  • 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

Blepharospasms † 1

Spastic Conditions 1

  • Patient has one of the following:
    • Upper Limb spasticity in adults (i.e., used post-stroke for spasms)
    • Pediatric upper limb spasticity in patients aged 2 years to 17 years of age, excluding spasticity caused by cerebral palsy

Prophylaxis for Chronic Migraines ‡ 3,8,10

  • Not used in combination with prophylactic calcitonin gene-related peptide (CGRP) inhibitors (i.e., eptinezumab, erenumab, galcanezumab, fremanezumab, etc.) [NOTE: This does not include CGRP inhibitors used for acute treatment (e.g., ubrogepant)]; 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)

Incontinence due to neurogenic detrusor overactivity ‡ 7,9,19

  • Patient has detrusor overactivity associated with a neurologic condition (i.e., spinal cord injury, multiple sclerosis, etc.) that is confirmed by urodynamic testing; AND
  • Patient has failed a 1 month or longer trial of two medications from either the antimuscarinic (i.e., darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine or trospium) or beta-adrenergic (i.e., mirabegron) classes.

Overactive Bladder (OAB) 7,9,19  

  • Patient has symptoms of urge urinary incontinence, urgency, and frequency; AND
  • Patient has failed a 1 month or longer trial of two medications from either the antimuscarinic (i.e., darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine or trospium) or beta-adrenergic (i.e., mirabegron) classes.

Severe Primary Axillary Hyperhidrosis ‡ 4,5,6

  • 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.)

Chronic Sialorrhea † 1,13,22

  • Patient has a history of troublesome sialorrhea for at least a 3 month period; AND
    • Patient has Parkinson’s disease, atypical Parkinsonism, stroke, or traumatic brain injury; OR
    • Patient has a severe developmental delay ; OR
    • Patient has cerebral palsy, other genetic or congenital disorders, or traumatic brain injury ; AND
      • Patient is at least 2 years of age

Ventral Hernia ‡ 20,21

  • Patient has a large ventral hernia with loss of domain or contaminated ventral hernia; AND
  • Used preoperatively in patients scheduled to receive abdominal wall reconstruction (AWR)

FDA Approved Indication(s); Literature Supported Indication

Migraine-Prophylaxis Oral Medications (list not all-inclusive) 11,12,16

  • 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 § 23

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 three of the following characteristics:
  • At least one aura symptom spreads gradually over ≥5 minutes
  • Two or more symptoms occur in succession
  • Each individual aura symptom lasts 5 to 60 minutes
  • At least one aura symptom is unilateral
  • At least one aura symptom is positive (e.g., scintillations and pins and needles)
  • The aura is accompanied, or followed within 60 minutes, by headache
  1. Renewal Criteria 1-23

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, generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, breathing difficulties, etc.), hypersensitivity reactions, corneal exposure/ulceration, ectropion in patients treated for blepharospasm, etc.; AND
  • Disease response as evidenced by the following:

Blepharospasms

  • Improvement of severity and/or frequency of eyelid spasms

Cervical dystonia

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

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.)

Severe primary axillary hyperhidrosis

  • Significant reduction in spontaneous axillary sweat production; AND
  • Patient has a significant improvement in activities of daily living

Prophylaxis for chronic migraines 10

  • 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.)

Incontinence due to detrusor overactivity

  • Significant improvements in weekly frequency of incontinence episodes; AND
  • Patient’s post-void residual (PVR) periodically assessed as medically appropriate

Overactive bladder (OAB)

  • Significant improvement in daily frequency of urinary incontinence or micturition episodes and/or volume voided per micturition; AND
  • Patient’s post-void residual (PVR) periodically assessed as medically appropriate

Chronic Sialorrhea

  • Significant decrease in saliva production

Ventral Hernias

  • May not be renewed.
  1. Dosage/Administration 1-23

Indication

Dose

Cervical Dystonia

The recommended initial total dose for cervical dystonia is 120 units.  Initial dose is divided among the affected muscles every 12 weeks or longer, as necessary

Blepharospasm

1.25-5.6 units per injection site, not to exceed 50 units per eye (maximum of 35 units per eye for initial dose), every 12 weeks or longer, as necessary

Upper limb spasticity

The dosage, frequency, and number of injection sites should be tailored to the individual patient based on the size, number, and location of muscles to be treated, severity of spasticity, presence of local muscle weakness, patient’s response to previous treatment, and adverse event history with Xeomin. Localization of the involved muscles with electromyographic guidance, nerve stimulation, or ultrasound techniques is recommended.

Adults

Up to 400 units total, repeated no sooner than every 12 weeks

Pediatrics

8 units/kg, divided among affected muscles, up to a maximum dose of 200 units per single upper limb. If both upper limbs are treated, total XEOMIN dosage should not exceed 16 Units/kg, up to a maximum of 400 units, repeated no sooner than every 12 weeks

Chronic Migraine

Up to 200 units divided among the affected muscles every 12 weeks

Severe primary axillary hyperhidrosis

50 units intradermally per axilla every 16 weeks

Neurogenic bladder/ Detrusor overactivity

Up to 200 units per treatment divided among the affected muscles every 12 weeks.

Overactive Bladder (OAB)

Up to 100 units per treatment divided among the affected muscles every 12 weeks

Sialorrhea

Adults

30 units per parotid gland and 20 units per submandibular gland (50 units per each side of the face for a total recommended dose of 100 units per treatment session), repeated no sooner than every 16 weeks

Pediatrics: Dosing is based on body weight as noted below and is repeated no sooner than every 16 weeks

  • 12 kg to <15 kg: 6 units per parotid gland and 4 units per submandibular gland (10 units per each side of the face for a total recommended dose of 20 units per treatment session)
  • 15 kg to <19 kg: 9 units per parotid gland and 6 units per submandibular gland (15 units per each side of the face for a total recommended dose of 30 units per treatment session)
  • 19 kg to <23 kg: 12 units per parotid gland and 8 units per submandibular gland (20 units per each side of the face for a total recommended dose of 40 units per treatment session)
  • 23 kg to <27 kg: 15 units per parotid gland and 10 units per submandibular gland (25 units per each side of the face for a total recommended dose of 50 units per treatment session)
  • 27 kg to <30 kg: 18 units per parotid gland and 12 units per submandibular gland (30 units per each side of the face for a total recommended dose of 60 units per treatment session)
  • 30 kg or more: 22.5 units per parotid gland and 15 units per submandibular gland (37.5 units per each side of the face for a total recommended dose of 75 units per treatment session)

Ventral Hernia

500 units divided among abdominal muscles, injected 2-4 weeks prior to AWR surgery.  May not be renewed.

Note: The recommended maximum cumulative dose for any indication should not exceed 400 Units in a treatment session (unless used for Ventral Hernia).

  1. Billing Code/Availability Information

HCPCS Code:

  • J0588 – Injection, incobotulinumtoxinA, 1 unit; 1 billable unit = 1 unit

NDC(s):

  • Xeomin 50 unit powder for injection; single-dose vial: 00259-1605-xx        
  • Xeomin 100 unit powder for injection; single-dose vial: 00259-1610-xx        
  • Xeomin 200 unit powder for injection; single-dose vial :00259-1620-xx        
  1. References
  2. Xeomin [package insert].  Dessau-Rosslau, Germany; Merz Group Services GmbH; April 2021. Accessed April 2021.
  3. 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
  4. Grogan P, Robinson A, Chao W, Ford A. Incobotulinumtoxin A for the Preventive Treatment of Chronic Migraine Headaches. Neurology April 8, 2014 vol. 82 no. 10 Supplement P7.188
  5. Lakraj AA1, Moghimi N, Jabbari B. Hyperhidrosis: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins (Basel). 2013 Apr 23; 5(4):821-40. doi: 10.3390/toxins5040821.
  6. Pastorelli F, Michelucci R, Plasmati R. A Randomized Controlled Trial Comparing Botulinum Toxin Type A Xeomin ® and Dysport ® for Treatment Of Primary Axillary Hyperhidrosis (P3.021). Neurology April 8, 2014 vol. 82 no. 10 Supplement P3.021
  7. Dressler D. Routine use of Xeomin in patients previously treated with Botox: long term results. Eur J Neurol. 2009 Dec; 16 Suppl 2:2-5. doi: 10.1111/j.1468-1331.2009.02877.x.
  8. Hampel C, D’Andrea D, Gillitzer R, et al. Comparison of two different Botulinumtoxin A products (Xeomin, Botox) used for detrusor injection in patients with bladder overactivity (BO) – a prospective randomized double-blind study. Paper presented at: the 27th Annual European Association of Urology (EAU) Congress - February 24 - 28, 2012 - Le Palais des Congrès de Paris, Paris, France
  9. 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.
  10. Gormley EA, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: American Urological Association (AUA)/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) guideline. April 2019.
  11. Schwedt TJ. Chronic Migraine. BMJ. 2014;348:g1416.
  12. Modi S, Lowder DM. Medications for migraine prophylaxis. Am Fam Physician. 2006 Jan 1; 73(1):72-8.
  13. 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.
  14. Blitzer A, Friedman A, Michel O, et al. SIAXI: IncobotulinumtoxinA for Sialorrhea in Parkinson’s Disease, Stroke, and Other Etiologies-Phase III results. Archives of Physical Medicine and Rehabilitation, 2017 Dec. Volume 98, Issue 12, e161.
  15. Jost W, Friedman A, Michel O, et al. SIAXI: Efficacy and safety of Xeomin (incobotulinumtoxinA) for the treatment of sialorrhea in Parkinson’s disease (PD) and other neurological conditions: Results of a Phase III, placebo-controlled, randomized, double-blind study (S2.007). Neurology Apr 2018, 90 (15 Supplement) S2.007;
  16. 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
  17. 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.
  18. Haider A, Solish N. Focal hyperhidrosis: diagnosis and management. CMAJ. 2005;172(1):69-75.
  19. 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.
  20. Kuo HC, Chen SL, Chou CL, et al. Taiwanese Continence Society clinical guidelines for diagnosis and management of neurogenic lower urinary tract dysfunction. Urological Science, Volume 25, Issue 2, 2014, pp. 35-41
  21. Motz BM, Schlosser KA, Heniford BT. Chemical Components Separation: Concepts, Evidence, and Outcomes. Plast Reconstr Surg. 2018 Sep;142(3 Suppl):58S-63S. doi: 10.1097/PRS.0000000000004856.
  22. Elstner KE, Read JW, Saunders J, et al. Selective muscle botulinum toxin A component paralysis in complex ventral hernia repair. Hernia. 2019 Apr 4. doi: 10.1007/s10029-019-01939-3.
  23. Merz Pharmaceuticals. Clinical Study to Investigate the Efficacy and Safety of NT 201 Compared to Placebo in the Treatment of Chronic Troublesome Drooling Associated With Neurological Disorders and/or Intellectual Disability (SIPEXI). Available from: https://clinicaltrials.gov/ct2/show/NCT02270736?cond=incobotulinumtoxinA+for+sialorrhea&draw=2&rank=3. NLM identifier: NCT02270736. Accessed December 22, 2020
  24. The International Classification of Headache Disorders, 3rd edition (beta version).Headache Classification Committee of the International Headache Society (IHS) Cephalalgia. 2018 Jan;38(1):1-211.
  25. 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 2021.
  26. 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 12/16/2020 with effective date 10/1/2010. Accessed April 2021.
  27. 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 03/23/2021 with effective date 04/01/2021. Accessed April 2021
  28. CGS, Administrators, LLC. Local Coverage Article: Billing and Coding: Billing and Coding for Botulinum Toxins (A56472). Centers for Medicare & Medicaid Services, Inc. Updated on 11/16/2010 with effective date 11/21/2020. Accessed April 2021.
  29. 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 12/16/2020 with effective date 10/01/2010. Accessed April 2021.
  30. Palmetto GBA. Local Coverage Article: Billing and Coding: Chemodenervation (A56646). Centers for Medicare & Medicaid Services, Inc. Updated on 01/29/2021 with effective date 01/01/2021. Accessed April 2021.
  31. Palmetto GBA. Local Coverage Article: Billing and Coding: Upper Gastrointestinal Endoscopy and Visualization (A56389). Centers for Medicare & Medicaid Services, Inc. Updated on 02/26/2021 with effective date 01/01/2021. Accessed April 2021.
  32. First Coast Service Options, Inc. Local Coverage Article: Billing and Coding: Botulinum Toxins (A57715). Centers for Medicare & Medicaid Services, Inc. Updated on 01/29/2021 with effective date 03/21/2021. Accessed April 2021.
  33. Novitas Solutions, Inc. Local Coverage Article: Billing and Coding: Botulinum Toxins (A58423). Centers for Medicare & Medicaid Services, Inc. Updated on 01/29/2021 with effective date 03/21/2021. Accessed April 2021.

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

G24.3

Spasmodic torticollis

G24.5

Blepharospasm

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 secretion

K43.6

Other and unspecified ventral hernia with obstruction, without gangrene

K43.7

Other and unspecified ventral hernia with gangrene

K43.9

Ventral hernia without obstruction or gangrene

M43.6

Torticollis

N31.0

Uninhibited neuropathic bladder, not elsewhere classified

N31.1

Reflex neuropathic bladder, not elsewhere classified

N31.8

Other neuromuscular dysfunction of bladder

N31.9

Neuromuscular dysfunction of bladder, unspecified

N32.81

Overactive bladder

L74.510

Primary focal hyperhidrosis, axilla

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):  J & M

NCD/LCD/LCA Document (s): A56646

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=56646&ver=12&bc=CAAAAAAAAAAA

Jurisdiction(s): 5& 8

NCD/LCD/LCA Document (s): A57474

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=57474&ver=14&bc=CAAAAAAAAAAA

Jurisdiction(s): 6& K

NCD/LCD/LCA Document (s): A52848

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52848&ver=18&bc=CAAAAAAAAAAA

Jurisdiction(s): 15

NCD/LCD/LCA Document (s): A56472

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=56472&ver=13&bc=CAAAAAAAAAAA

Jurisdiction(s): F

NCD/LCD/LCA Document (s): A57186

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=57186&ver=6&bc=CAAAAAAAAAAA

Jurisdiction(s): E

NCD/LCD/LCA Document (s): A57185

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=57185&ver=6&bc=CAAAAAAAAAAA  

Jurisdiction(s): J & M

NCD/LCD/LCA Document (s): A56389

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=56389&ver=15&bc=CAAAAAAAAAAA

Jurisdiction(s): N

NCD/LCD/LCA Document (s): A57715

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

Jurisdiction(s): H & L

NCD/LCD/LCA Document (s): A58423

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A58423&bc=gAAAAAAAAAAA 

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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