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Medical Policy Revision: Botulinum Toxin

Effective June 20, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for botulinum toxin treatments/injections.

Our revised medical policy, Botulinum Toxin, identifies the circumstances and conditions under which botulinum toxin treatments/injections will be considered medically necessary for members enrolled in Horizon BCBSNJ Medicare Advantage plans.*

We encourage you to review this policy in our online Medical Policy Manual.

*Please note that the implementation of these current policy revisions will align the way we will consider and process claims for botulinum toxin treatments/injections provided to members enrolled in Medicare Advantage plans with how we currently consider and process claims for botulinum toxin treatments/injections provided to members enrolled in commercial plans.

Based on the guidelines of our medical policy, Botulinum Toxin and the submitted diagnosis codes(s):

  • Claims submitted for services provided on and after June 20, 2016 to members enrolled in Horizon BCBSNJ Medicare Advantage plans that include CPT® codes 31513, 31570, 31571, 43201, 43236, 46505, 64612, 64615, 64616, 64617, 64640, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, 67345, +95873 or +95874 may pend while information to help us determine if the service(s) in question is to be considered medically necessary is requested and reviewed.

    Following our review of the requested information, services that are not considered medically necessary based on the guidelines of our medical policy, Botulinum Toxin, may be denied as cosmetic or investigational services.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after June 20, 2016.

CPT® is a registered mark of the American Medical Association.

Published on: March 21, 2016, 10:00 a.m. ET
Last updated on: November 25, 2020, 00:19 a.m. ET