Prior Authorization Details

General Documentation Requirements for Botulinum Toxin Injections

Prior authorization is only required when one of the required Botulinum Toxin codes (J0585, J0586, J0587, or J0588) is used in conjunction with one of the required CPT injection codes (64612, injection of chemical for destruction of nerve muscles on one side of face, or 64615, injection of chemical for destruction of facial and neck nerve muscles on both sides of face). Use of these Botulinum Toxin codes in conjunction/paired with procedure codes other than 64612 or 64615 will not require PA under this program.

  • A covered diagnosis
  • Dosage and frequency of planned injections
  • Specific site(s) injected (refer to your MAC's LCD/LCA)
  • Documentation to support the medical necessity when electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s) (when applicable)
  • To support continuous treatment, the documentation should include the clinical effectiveness of two consecutive treatments that preceded the anticipated procedure (refer to your MAC’s LCD/LCA)
  • Documentation of the management of a chronic migraine diagnosis. A medical record must include a history of migraine and experiencing frequent headaches on most days of the month
  • Documentation of traditional treatments such as medication, physical therapy, and other appropriate methods have been tried and proven unsuccessful (when applicable).

This checklist is not all inclusive; please submit any additional medical records that help support the medical necessity of the Hospital Outpatient Department service.

A facility or the beneficiary may submit the PAR and supplemental documentation via NGSConnex, esMD, fax or mail.

  • NGSConnex
  • esMD: Content type 8.5
  • Fax
    JK: 317-841-4530
    J6: 317-841-4528
  • Mail
    National Government Services, Inc.
    Attention: Medical Review Prior Authorization Request
    P.O. Box 7108
    Indianapolis, IN 46207-7108

Provider Contact Center Inquiry Line:

  • JK: 888-855-4356
  • J6: 877-702-0990

Related Content:

PAR decisions and the unique tracking numbers assigned for these services will be valid for 120 days. The decision date shall be counted as the first day of the 120 days. For example: if the PAR is affirmed on 1/1/2021, the PAR will be valid for dates of service through 4/30/2021. Otherwise, the provider will need to submit a new PAR.