Botulinum Toxin LCD Coverage Update

A recently implemented Novitas and First Coast Local Coverage Determination (LCD) and companion billing article for botulinum toxin significantly narrowed the ICD-10 diagnoses under which chemodenervation is considered medically appropriate. The policy excluded common paralysis diagnoses such as paraplegia and monoplegia because the codes do not explicitly reference “spasticity,” raising concerns about inappropriate coverage denials for patients with spasticity following stroke, spinal cord injury, and other neuromuscular conditions routinely evaluated and treated by AANEM members.​

AANEM has been closely tracking this issue and engaged with AAPM&R and AAN to understand its implications for NM patient care, documentation, and coding practices. Following sustained advocacy led by AAPM&R and supported by physiatry stakeholders, including AANEM, the MAC medical directors agreed to a short-term solution: paralysis codes such as paraplegia and monoplegia may now be used when paired with ICD10 code M62.838 (other muscle spasm), restoring coverage for many appropriate chemodenervation cases.

AANEM and other specialty societies will continue to engage with CMS and the MACs on longer-term solutions, including potential targeted ICD-10 revisions to more accurately reflect spasticity associated with paralysis without requiring workaround coding combinations.