Page reviewed Aug 23, 2026 · from CMS Article A52848 (CMS last revised 09/17/2025)
Quick answer
Medicare benefit
Part B (physician-administered)
Covered diagnoses
313 ICD-10 codes
Governing policy
A52848 / L33646
Contractor (MAC)
National Government Services, Inc.
CMS article revised
09/17/2025
Page reviewed
Aug 23, 2026
HCPCS codes covered:
J0585J0586J0587J0588J0589
J0585J0586J0587J0588J0589
Coverage varies by Medicare Administrative Contractor (MAC). This list is National Government Services, Inc.'s policy (Article A52848), which administers Part B in Illinois, Minnesota, Wisconsin, Connecticut, Maine, Massachusetts +4 more. In another state? Other MACs may publish a different covered list — find your MAC by state →
What Medicare pays for Botox (Botulinum Toxin) (2026 Q3)
Once a claim carries a covered diagnosis, Medicare Part B reimburses the drug at the ASP + 6% payment limit. Current allowed amounts per billing unit:
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J0585 | Injection,onabotulinumtoxina | 1 unit | $6.506 |
| J0586 | Abobotulinumtoxina | 5 unit | $8.946 |
| J0587 | Inj, rimabotulinumtoxinb | 100 units | $13.287 |
| J0588 | Incobotulinumtoxin a | 1 unit | $5.285 |
| J0589 | Inj daxibotulinumtoxina-lanm | 1 unit | $3.067 |
Source: CMS ASP Drug Pricing File, 2026 Q3. Payment = ASP + 6% per unit; multiply by units billed (watch JZ/JW wastage). Your patient's share is typically 20% after the deductible. Estimate the full cost & patient out-of-pocket →
Botox (Botulinum Toxin) is a physician-administered biologic billed under Medicare Part B (not the Part D pharmacy benefit). Under Part B, Medicare pays the practice for the drug (HCPCS J0585, J0586, J0587, J0588) plus its administration — but only when the claim's diagnosis (ICD-10) code supports medical necessity. Each MAC publishes the specific covered diagnoses in a Billing & Coding Article; a claim with a diagnosis outside that list is typically denied as not medically necessary (CO-50).
Covered ICD-10 diagnoses for Botox (Botulinum Toxin)
The 313 codes below are the diagnoses National Government Services, Inc. accepts for J0585 under Article A52848, grouped exactly as CMS groups them and organized by condition category for scanning. Use the filter in each group to find a specific code or condition.
Group 1 — 1 covered diagnoses
CPT code 64611 (used for injection of salivary glands for sialorrhea)
Diseases of the digestive system (1)
| ICD-10 | Covered diagnosis |
|---|---|
| K11.7 | Disturbances of salivary secretion |
Group 2 — 1 covered diagnoses
For CPT codes 43201, 43236
Diseases of the digestive system (1)
| ICD-10 | Covered diagnosis |
|---|---|
| K22.0 | Achalasia of cardia |
Group 3 — 3 covered diagnoses
For CPT code 46505
Diseases of the digestive system (3)
| ICD-10 | Covered diagnosis |
|---|---|
| K60.0 | Acute anal fissure |
| K60.1 | Chronic anal fissure |
| K60.2 | Anal fissure, unspecified |
Group 4 — 9 covered diagnoses
For CPT code 52287
Diseases of the genitourinary system (8)
| ICD-10 | Covered diagnosis |
|---|---|
| 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 |
| N36.44 | Muscular disorders of urethra |
| N39.41 | Urge incontinence |
| N39.46 | Mixed incontinence |
Diseases of the nervous system (1)
| ICD-10 | Covered diagnosis |
|---|---|
| G83.4 | Cauda equina syndrome |
Group 5 — 8 covered diagnoses
For CPT code 64612
Diseases of the nervous system (8)
| ICD-10 | Covered diagnosis |
|---|---|
| G24.4 | Idiopathic orofacial dystonia |
| G24.5 | Blepharospasm |
| G51.2 | Melkersson's syndrome |
| G51.31 | Clonic hemifacial spasm, right |
| G51.32 | Clonic hemifacial spasm, left |
| G51.33 | Clonic hemifacial spasm, bilateral |
| G51.4 | Facial myokymia |
| G51.8 | Other disorders of facial nerve |
Group 6 — 2 covered diagnoses (applies to J0589)
For CPT code 64616 Only ICD-10-CM code G24.3 supports the medical necessity and provides coverage for HCPCS code J0589.
Diseases of the nervous system (1)
| ICD-10 | Covered diagnosis |
|---|---|
| G24.3 | Spasmodic torticollis |
Diseases of the musculoskeletal system & connective tissue (1)
| ICD-10 | Covered diagnosis |
|---|---|
| M43.6 | Torticollis |
Group 7 — 1 covered diagnoses
For CPT code 64617
Diseases of the respiratory system (1)
| ICD-10 | Covered diagnosis |
|---|---|
| J38.5 | Laryngeal spasm |
Group 8 — 178 covered diagnoses
For CPT code 64642, 64643, 64644, 64645, 64646 and 64647 Use ICD-10-CM code M62.411 through M62.838 (spasm of muscle) to report treatment of spasticity secondary to spastic hemiplegia and hemiparesis.
Diseases of the circulatory system (102)
| ICD-10 | Covered diagnosis |
|---|---|
| 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 |
| I69.041 | Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right dominant side |
| I69.042 | Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left dominant side |
| I69.043 | Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right non-dominant side |
| I69.044 | Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant 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 |
| I69.061 | Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting right dominant side |
| I69.062 | Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting left dominant side |
| I69.063 | Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting right non-dominant side |
| I69.064 | Other paralytic syndrome following nontraumatic subarachnoid hemorrhage affecting left non-dominant side |
| I69.065 | Other paralytic syndrome following nontraumatic subarachnoid hemorrhage, bilateral |
| 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 |
| I69.141 | Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right dominant side |
| I69.142 | Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left dominant side |
| I69.143 | Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right non-dominant side |
| I69.144 | Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side |
| 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 |
| I69.161 | Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting right dominant side |
| I69.162 | Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting left dominant side |
| I69.163 | Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting right non-dominant side |
| I69.164 | Other paralytic syndrome following nontraumatic intracerebral hemorrhage affecting left non-dominant side |
| I69.165 | Other paralytic syndrome following nontraumatic intracerebral hemorrhage, bilateral |
| 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 |
| I69.241 | Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right dominant side |
| I69.242 | Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left dominant side |
| I69.243 | Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side |
| I69.244 | Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side |
| 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 |
| I69.261 | Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting right dominant side |
| I69.262 | Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting left dominant side |
| I69.263 | Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting right non-dominant side |
| I69.264 | Other paralytic syndrome following other nontraumatic intracranial hemorrhage affecting left non-dominant side |
| I69.265 | Other paralytic syndrome following other nontraumatic intracranial hemorrhage, bilateral |
| 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 |
| I69.341 | Monoplegia of lower limb following cerebral infarction affecting right dominant side |
| I69.342 | Monoplegia of lower limb following cerebral infarction affecting left dominant side |
| I69.343 | Monoplegia of lower limb following cerebral infarction affecting right non-dominant side |
| I69.344 | Monoplegia of lower limb following cerebral infarction affecting left non-dominant side |
| 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 |
| I69.361 | Other paralytic syndrome following cerebral infarction affecting right dominant side |
| I69.362 | Other paralytic syndrome following cerebral infarction affecting left dominant side |
| I69.363 | Other paralytic syndrome following cerebral infarction affecting right non-dominant side |
| I69.364 | Other paralytic syndrome following cerebral infarction affecting left non-dominant side |
| I69.365 | Other paralytic syndrome following cerebral infarction, bilateral |
| 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 |
| I69.841 | Monoplegia of lower limb following other cerebrovascular disease affecting right dominant side |
| I69.842 | Monoplegia of lower limb following other cerebrovascular disease affecting left dominant side |
| I69.843 | Monoplegia of lower limb following other cerebrovascular disease affecting right non-dominant side |
| I69.844 | Monoplegia of lower limb following other cerebrovascular disease affecting left non-dominant side |
| 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 |
| I69.861 | Other paralytic syndrome following other cerebrovascular disease affecting right dominant side |
| I69.862 | Other paralytic syndrome following other cerebrovascular disease affecting left dominant side |
| I69.863 | Other paralytic syndrome following other cerebrovascular disease affecting right non-dominant side |
| I69.864 | Other paralytic syndrome following other cerebrovascular disease affecting left non-dominant side |
| I69.865 | Other paralytic syndrome following other cerebrovascular disease, bilateral |
| 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 |
| I69.941 | Monoplegia of lower limb following unspecified cerebrovascular disease affecting right dominant side |
| I69.942 | Monoplegia of lower limb following unspecified cerebrovascular disease affecting left dominant side |
| I69.943 | Monoplegia of lower limb following unspecified cerebrovascular disease affecting right non-dominant side |
| I69.944 | Monoplegia of lower limb following unspecified cerebrovascular disease affecting left non-dominant 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 |
| I69.961 | Other paralytic syndrome following unspecified cerebrovascular disease affecting right dominant side |
| I69.962 | Other paralytic syndrome following unspecified cerebrovascular disease affecting left dominant side |
| I69.963 | Other paralytic syndrome following unspecified cerebrovascular disease affecting right non-dominant side |
| I69.964 | Other paralytic syndrome following unspecified cerebrovascular disease affecting left non-dominant side |
| I69.965 | Other paralytic syndrome following unspecified cerebrovascular disease, bilateral |
Diseases of the nervous system (58)
| ICD-10 | Covered diagnosis |
|---|---|
| G11.4 | Hereditary spastic paraplegia |
| G24.1 | Genetic torsion dystonia |
| G24.2 | Idiopathic nonfamilial dystonia |
| G24.8 | Other dystonia |
| G24.9 | Dystonia, unspecified |
| G25.89 | Other specified extrapyramidal and movement disorders |
| G35.A | Relapsing-remitting multiple sclerosis |
| G35.B0 | Primary progressive multiple sclerosis, unspecified |
| G35.B1 | Active primary progressive multiple sclerosis |
| G35.B2 | Non-active primary progressive multiple sclerosis |
| G35.C0 | Secondary progressive multiple sclerosis, unspecified |
| G35.C1 | Active secondary progressive multiple sclerosis |
| G35.C2 | Non-active secondary progressive multiple sclerosis |
| G35.D | Multiple sclerosis, unspecified |
| G36.0 | Neuromyelitis optica [Devic] |
| G36.1 | Acute and subacute hemorrhagic leukoencephalitis [Hurst] |
| G36.8 | Other specified acute disseminated demyelination |
| G36.9 | Acute disseminated demyelination, unspecified |
| G37.0 | Diffuse sclerosis of central nervous system |
| G37.1 | Central demyelination of corpus callosum |
| G37.2 | Central pontine myelinolysis |
| G37.3 | Acute transverse myelitis in demyelinating disease of central nervous system |
| G37.4 | Subacute necrotizing myelitis of central nervous system |
| G37.5 | Concentric sclerosis [Balo] of central nervous system |
| G37.9 | Demyelinating disease of central nervous system, unspecified |
| G80.0 | Spastic quadriplegic cerebral palsy |
| G80.1 | Spastic diplegic cerebral palsy |
| G80.2 | Spastic hemiplegic cerebral palsy |
| G80.3 | Athetoid cerebral palsy |
| G80.4 | Ataxic cerebral palsy |
| G80.8 | Other cerebral palsy |
| G80.9 | Cerebral palsy, unspecified |
| 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 |
| G82.21 | Paraplegia, complete |
| G82.22 | Paraplegia, incomplete |
| G82.50 | Quadriplegia, unspecified |
| G82.51 | Quadriplegia, C1-C4 complete |
| G82.52 | Quadriplegia, C1-C4 incomplete |
| G82.53 | Quadriplegia, C5-C7 complete |
| G82.54 | Quadriplegia, C5-C7 incomplete |
| G83.0 | Diplegia of upper limbs |
| G83.10 | Monoplegia of lower limb affecting unspecified side |
| G83.11 | Monoplegia of lower limb affecting right dominant side |
| G83.12 | Monoplegia of lower limb affecting left dominant side |
| G83.13 | Monoplegia of lower limb affecting right nondominant side |
| G83.14 | Monoplegia of lower limb affecting left nondominant side |
| 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 |
| G83.81 | Brown-Sequard syndrome |
| G83.82 | Anterior cord syndrome |
| G83.89 | Other specified paralytic syndromes |
Diseases of the musculoskeletal system & connective tissue (18)
| ICD-10 | Covered diagnosis |
|---|---|
| M62.411 | Contracture of muscle, right shoulder |
| M62.412 | Contracture of muscle, left shoulder |
| M62.421 | Contracture of muscle, right upper arm |
| M62.422 | Contracture of muscle, left upper arm |
| M62.431 | Contracture of muscle, right forearm |
| M62.432 | Contracture of muscle, left forearm |
| M62.441 | Contracture of muscle, right hand |
| M62.442 | Contracture of muscle, left hand |
| M62.451 | Contracture of muscle, right thigh |
| M62.452 | Contracture of muscle, left thigh |
| M62.461 | Contracture of muscle, right lower leg |
| M62.462 | Contracture of muscle, left lower leg |
| M62.471 | Contracture of muscle, right ankle and foot |
| M62.472 | Contracture of muscle, left ankle and foot |
| M62.48 | Contracture of muscle, other site |
| M62.49 | Contracture of muscle, multiple sites |
| M62.831 | Muscle spasm of calf |
| M62.838 | Other muscle spasm |
Group 9 — 1 covered diagnoses
For CPT codes 64650, 64653 Indication is for severe primary axillary hyperhidrosis
Diseases of the skin & subcutaneous tissue (1)
| ICD-10 | Covered diagnosis |
|---|---|
| L74.510 | Primary focal hyperhidrosis, axilla |
Group 10 — 87 covered diagnoses
For CPT code 67345
Diseases of the eye & adnexa (87)
| ICD-10 | Covered diagnosis |
|---|---|
| H02.041 | Spastic entropion of right upper eyelid |
| H02.042 | Spastic entropion of right lower eyelid |
| H02.044 | Spastic entropion of left upper eyelid |
| H02.045 | Spastic entropion of left lower eyelid |
| H02.141 | Spastic ectropion of right upper eyelid |
| H02.142 | Spastic ectropion of right lower eyelid |
| H02.144 | Spastic ectropion of left upper eyelid |
| H02.145 | Spastic ectropion of left lower eyelid |
| H49.01 | Third [oculomotor] nerve palsy, right eye |
| H49.02 | Third [oculomotor] nerve palsy, left eye |
| H49.03 | Third [oculomotor] nerve palsy, bilateral |
| H49.11 | Fourth [trochlear] nerve palsy, right eye |
| H49.12 | Fourth [trochlear] nerve palsy, left eye |
| H49.13 | Fourth [trochlear] nerve palsy, bilateral |
| H49.21 | Sixth [abducent] nerve palsy, right eye |
| H49.22 | Sixth [abducent] nerve palsy, left eye |
| H49.23 | Sixth [abducent] nerve palsy, bilateral |
| H49.31 | Total (external) ophthalmoplegia, right eye |
| H49.32 | Total (external) ophthalmoplegia, left eye |
| H49.33 | Total (external) ophthalmoplegia, bilateral |
| H49.41 | Progressive external ophthalmoplegia, right eye |
| H49.42 | Progressive external ophthalmoplegia, left eye |
| H49.43 | Progressive external ophthalmoplegia, bilateral |
| H49.881 | Other paralytic strabismus, right eye |
| H49.882 | Other paralytic strabismus, left eye |
| H49.883 | Other paralytic strabismus, bilateral |
| H50.00 | Unspecified esotropia |
| H50.011 | Monocular esotropia, right eye |
| H50.012 | Monocular esotropia, left eye |
| H50.021 | Monocular esotropia with A pattern, right eye |
| H50.022 | Monocular esotropia with A pattern, left eye |
| H50.031 | Monocular esotropia with V pattern, right eye |
| H50.032 | Monocular esotropia with V pattern, left eye |
| H50.041 | Monocular esotropia with other noncomitancies, right eye |
| H50.042 | Monocular esotropia with other noncomitancies, left eye |
| H50.05 | Alternating esotropia |
| H50.06 | Alternating esotropia with A pattern |
| H50.07 | Alternating esotropia with V pattern |
| H50.08 | Alternating esotropia with other noncomitancies |
| H50.10 | Unspecified exotropia |
| H50.111 | Monocular exotropia, right eye |
| H50.112 | Monocular exotropia, left eye |
| H50.121 | Monocular exotropia with A pattern, right eye |
| H50.122 | Monocular exotropia with A pattern, left eye |
| H50.131 | Monocular exotropia with V pattern, right eye |
| H50.132 | Monocular exotropia with V pattern, left eye |
| H50.141 | Monocular exotropia with other noncomitancies, right eye |
| H50.142 | Monocular exotropia with other noncomitancies, left eye |
| H50.15 | Alternating exotropia |
| H50.16 | Alternating exotropia with A pattern |
| H50.17 | Alternating exotropia with V pattern |
| H50.18 | Alternating exotropia with other noncomitancies |
| H50.21 | Vertical strabismus, right eye |
| H50.22 | Vertical strabismus, left eye |
| H50.30 | Unspecified intermittent heterotropia |
| H50.311 | Intermittent monocular esotropia, right eye |
| H50.312 | Intermittent monocular esotropia, left eye |
| H50.32 | Intermittent alternating esotropia |
| H50.331 | Intermittent monocular exotropia, right eye |
| H50.332 | Intermittent monocular exotropia, left eye |
| H50.34 | Intermittent alternating exotropia |
| H50.40 | Unspecified heterotropia |
| H50.411 | Cyclotropia, right eye |
| H50.412 | Cyclotropia, left eye |
| H50.42 | Monofixation syndrome |
| H50.43 | Accommodative component in esotropia |
| H50.50 | Unspecified heterophoria |
| H50.51 | Esophoria |
| H50.52 | Exophoria |
| H50.53 | Vertical heterophoria |
| H50.54 | Cyclophoria |
| H50.55 | Alternating heterophoria |
| H50.60 | Mechanical strabismus, unspecified |
| H50.611 | Brown's sheath syndrome, right eye |
| H50.612 | Brown's sheath syndrome, left eye |
| H50.69 | Other mechanical strabismus |
| H50.811 | Duane's syndrome, right eye |
| H50.812 | Duane's syndrome, left eye |
| H50.89 | Other specified strabismus |
| H51.0 | Palsy (spasm) of conjugate gaze |
| H51.11 | Convergence insufficiency |
| H51.12 | Convergence excess |
| H51.21 | Internuclear ophthalmoplegia, right eye |
| H51.22 | Internuclear ophthalmoplegia, left eye |
| H51.23 | Internuclear ophthalmoplegia, bilateral |
| H51.8 | Other specified disorders of binocular movement |
| H51.9 | Unspecified disorder of binocular movement |
Group 11 — 22 covered diagnoses
For CPT code 64615 Coverage will only be allowed for those patients with chronic daily headaches (headache disorders occurring greater than 15 days a month - in many cases daily with a duration of four or more hours - for a period of at least 3 months) who have significant disability due to the headaches, and have been refractory to standard and usual conventional therapy. The etiology of the chronic daily headache may be chronic tension-type headache or chronic migraine (CM). CM is characterized by headache on 15 days per month, of which at least 8 headache days per month meet criteria for migraine without aura or respond to migraine-specific treatment. For continuing Botulism toxin therapy the patients must demonstrate a significant decrease in the number and frequency of headaches and an improvement in function upon receiving Botulinum toxin. (Please see Indications and Limitations in the LCD)
Diseases of the nervous system (22)
| ICD-10 | Covered diagnosis |
|---|---|
| G43.001 | Migraine without aura, not intractable, with status migrainosus |
| G43.009 | Migraine without aura, not intractable, without status migrainosus |
| G43.011 | Migraine without aura, intractable, with status migrainosus |
| G43.019 | Migraine without aura, intractable, without status migrainosus |
| G43.101 | Migraine with aura, not intractable, with status migrainosus |
| G43.109 | Migraine with aura, not intractable, without status migrainosus |
| G43.111 | Migraine with aura, intractable, with status migrainosus |
| G43.119 | Migraine with aura, intractable, without status migrainosus |
| G43.701 | Chronic migraine without aura, not intractable, with status migrainosus |
| G43.709 | Chronic migraine without aura, not intractable, without status migrainosus |
| G43.711 | Chronic migraine without aura, intractable, with status migrainosus |
| G43.719 | Chronic migraine without aura, intractable, without status migrainosus |
| G43.901 | Migraine, unspecified, not intractable, with status migrainosus |
| G43.909 | Migraine, unspecified, not intractable, without status migrainosus |
| G43.911 | Migraine, unspecified, intractable, with status migrainosus |
| G43.919 | Migraine, unspecified, intractable, without status migrainosus |
| G43.E01 | Chronic migraine with aura, not intractable, with status migrainosus |
| G43.E09 | Chronic migraine with aura, not intractable, without status migrainosus |
| G43.E11 | Chronic migraine with aura, intractable, with status migrainosus |
| G43.E19 | Chronic migraine with aura, intractable, without status migrainosus |
| G44.221 | Chronic tension-type headache, intractable |
| G44.229 | Chronic tension-type headache, not intractable |
What commercial payers require for Botox (Botulinum Toxin)
Medicare Part B is only half the answer — most Botox (Botulinum Toxin) claims are adjudicated by a commercial plan with its own medical policy. Below is what 29 commercial payers publish for Botox (Botulinum Toxin), read from each payer's own policy document. 22 of 29 that state a position require prior authorization, and 4 run a site-of-care program that can push the infusion out of the hospital outpatient setting.
| Payer | Prior auth | Preferred product first | Site of care | Indications named | Policy date |
|---|---|---|---|---|---|
| Aetna policy ↗ | Required | — | — | 12 | 2026-07-14 |
| Anthem / Elevance policy ↗ | Not required | — | — | 12 | 2023-11-17 |
| Arkansas BCBS policy ↗ | Required | — | Site-of-care program applies | 12 | — |
| BCBS Federal Employee Program policy ↗ | Required | — | — | 1 | 2026-03-06 |
| BCBS Kansas policy ↗ | Not required | — | — | 10 | 2025-11-26 |
| BCBS Louisiana policy ↗ | Required | — | — | 9 | 2025-10-01 |
| BCBS Massachusetts policy ↗ | Required | — | — | 11 | — |
| BCBS Michigan policy ↗ | Required | — | — | 11 | 2025-10-09 |
| BCBS Minnesota policy ↗ | Required | — | — | 12 | 2025-12-02 |
| BCBS Mississippi policy ↗ | Required | — | — | 12 | — |
| BCBS Nebraska policy ↗ | Required | — | — | 1 | 2026-02-04 |
| BCBS South Carolina policy ↗ | Not required | — | — | 12 | — |
| BCBS Tennessee policy ↗ | Required | — | — | 12 | 2026-01-13 |
| Blue Shield of California policy ↗ | Required | — | Site-of-care program applies | 11 | 2023-03-29 |
| Capital BlueCross policy ↗ | Required | — | — | 12 | 2025-12-02 |
| CareFirst BCBS policy ↗ | Not required | — | — | 9 | — |
| Centene / Ambetter policy ↗ | Required | — | — | 12 | 2016-07-01 |
| Cigna policy ↗ | Required | — | — | 12 | — |
| Excellus BCBS policy ↗ | Not required | — | Site-of-care program applies | 12 | 2026-07-21 |
| Florida Blue policy ↗ | Required | — | — | 12 | 2026-02-15 |
| HCSC (IL/TX/OK/NM/MT) policy ↗ | Not required | — | — | 11 | 2025-05-15 |
| Highmark BCBS policy ↗ | Required | — | Site-of-care program applies | 12 | 2023-10-01 |
| HMSA (BCBS Hawaii) policy ↗ | Required | — | — | 1 | 2026-04-01 |
| Horizon BCBS NJ policy ↗ | Required | — | — | 4 | 2020-09-08 |
| Independence Blue Cross policy ↗ | Not required | — | — | 5 | 2022-02-10 |
| Premera Blue Cross policy ↗ | Required | — | — | 12 | 2026-02-01 |
| Regence BCBS policy ↗ | Required | — | — | 12 | 2026-04-01 |
| UnitedHealthcare policy ↗ | Required | — | — | 12 | 2026-01-01 |
| Wellmark BCBS policy ↗ | Required | — | — | 2 | 2026-03-28 |
What Botox (Botulinum Toxin) payers put in writing
Quoted from the medical policies linked above — 24 distinct requirements across 29 payers. These are the sentences an appeal has to answer.
Clinical prerequisites — what must be true before they pay
Prescribed by or in consultation with a neurologist or ophthalmologist
— Centene / Ambetter, Cigna, Excellus BCBS policy ↗Member completed an adequate trial of (or has a contraindication to) two migraine preventative therapies coming from at least 2 of the following classes
— Aetna, BCBS Tennessee policy ↗Member is 18 years of age or older
— Aetna, Florida Blue policy ↗Have symptoms that persist despite adequate trials of at least 2 agents from different classes of medications in the treatment of chronic migraine headaches (e.g., antidepressants, antihypertensives, and antiepileptics) (Garza, 2021)
— Arkansas BCBS, BCBS South Carolina policy ↗Patient is not on concurrent treatment with another botulinum toxin
— BCBS Minnesota, Capital BlueCross policy ↗Patient has failed a 1 month or longer trial of two medications from either the antimuscarinic (e.g., darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine or trospium, etc.) or beta- adrenergic (e.g., mirabegron, vibegron, etc.) classes
— BCBS Minnesota, Capital BlueCross policy ↗
Prior authorization
Precertification of botulinum toxin (Botox [onabotulinumtoxinA]; Daxxify [daxibotulinumtoxinA-lanm], Dysport [abobotulinumtoxinA]; Myobloc [rimabotulinumtoxinB]; and Xeomin [incobotulinumtoxinA]) is required of all Aetna participating providers and members in applicable plan designs.
— Aetna policy ↗Prior Approval is required for Botulinum Toxin (e.g., Botox).
— Arkansas BCBS policy ↗Botox may be considered medically necessary if the conditions indicated below are met.
— BCBS Federal Employee Program policy ↗Initiation of botulinum toxin [excluding letibotulinumtoxinA (Letybo) and prabotulinumtoxinA (Jeuveau)]
— Florida Blue policy ↗Botox™ (onabotulinumtoxin a) Preferred; PA required
— BCBS Massachusetts policy ↗Requests must be supported by submission of chart notes and patient specific documentation.
— BCBS Michigan policy ↗
Quantity and frequency limits
The recommended dose for treating chronic migraine is 155 Units administered intramuscularly; more than 200 Units is considered not medically necessary. The recommended re-treatment schedule is every 12 weeks.
— Aetna policy ↗The median time to retreatment is 24 weeks, but should be no sooner than 12 weeks.
— Aetna policy ↗The median time to retreatment is reported as 42 to 48 weeks.
— Aetna policy ↗Idiopathic Overactive Bladder: 100 units as frequently as every 12 weeks
— Anthem / Elevance policy ↗Neurogenic Overactive Bladder (including neurogenic detrusor overactivity in children age 5 and older): 200 units as frequently as every 12 weeks
— Anthem / Elevance policy ↗Chronic Migraine: 155 units as frequently as every 12 weeks
— Anthem / Elevance policy ↗
Dosing rules
Payment will be allowed for one injection per site regardless of the number of injections made into the site.
— Arkansas BCBS policy ↗Botox: 200 units (100 units per eye)
— Florida Blue policy ↗Botox: 300 units [billing max of 300 units]
— Florida Blue policy ↗Botox: 155 units [billing max of 200 units]
— Florida Blue policy ↗Botox: 400 units [billing max of 400 units]
— Florida Blue policy ↗Axilla: two sites, 100 units total
— Florida Blue policy ↗
Read from each payer's published medical policy between 2026-08-03 and 2026-08-13. Every requirement above is quoted from the policy it links to. Commercial policy changes without notice — confirm before you bill.
How to bill Botox (Botulinum Toxin)
Put the patient's covered ICD-10 diagnosis on the claim line with J0585. Matching codes, units and JZ/JW wastage →
Which policy governs Botox (Botulinum Toxin)
The covered code lists live in Article A52848 (tied to LCD L33646) — CMS moved code lists out of LCDs and into Articles, which is why the diagnoses live in the Article. What an LCD, an Article and an NCD each govern →
If a claim for Botox (Botulinum Toxin) is denied
The usual cause is a diagnosis outside Article A52848's covered list, or a product code and unit count that do not match what was given. The five denial patterns and how to fix each →
Frequently asked questions
- Is Botox (Botulinum Toxin) covered by Medicare?
- Yes. Botox (Botulinum Toxin) (J0585) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary, covered diagnosis. Local coverage is defined by National Government Services, Inc. in Billing & Coding Article A52848, tied to LCD L33646.
- What diagnoses are covered for Botox (Botulinum Toxin) (J0585)?
- Medicare lists 313 covered ICD-10 diagnosis codes for J0585 under Article A52848. The full list is on this page, grouped by condition category. Coverage can vary by Medicare Administrative Contractor (MAC); confirm against the article that applies in your state.
- Which Medicare policy covers Botox (Botulinum Toxin)?
- Billing & Coding Article A52848 (v42), tied to LCD L33646 (“Botulinum Toxins”), published by National Government Services, Inc. and last updated 09/17/2025.
- Why was my Botox (Botulinum Toxin) claim denied as not medically necessary?
- The most common cause is an ICD-10 diagnosis on the claim that is not in the covered list for J0585. Confirm the patient's diagnosis is in the groups below, that documentation supports medical necessity, and that you are using the article for your MAC.
Related references
Covered is only half the answer.
You know the diagnosis is payable. Now quote the patient before the visit and catch underpayments: get Botox (Botulinum Toxin)'s exact Medicare allowed amount, your payer's rate vs. ASP+6%, and the patient's out-of-pocket — in about 30 seconds, free.
Estimate Botox (Botulinum Toxin) cost & patient owe →Source & verification
- Source
- CMS Medicare Coverage Database — Billing & Coding Article A52848 (v42), LCD L33646 “Botulinum Toxins” — National Government Services, Inc..
- Primary sources
- DailyMed — Botox (Botulinum Toxin) prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — Article A52848
- CMS article last revised
- 09/17/2025
- Page last reviewed by CareCost
- Aug 23, 2026 (coverage data retrieved 2026-08-26; we re-verify against CMS quarterly).
- Code licensing
- ICD-10-CM codes are public domain (CMS/CDC). CPT® codes are AMA-copyrighted and are intentionally not listed here — see the administration-code reference for those.
- Not advice
- This is general billing reference, not legal or billing advice. Always verify against the LCD/Article that applies to your MAC and patient.
- How we build this
- Compiled programmatically from the CMS Coverage API under a founder-led methodology maintained by Erin Rose (Founder), and reviewed against the source article with a practitioner-correction loop. See our methodology and editorial policy.
- Spotted an error?
- Email editorial@carecostestimate.com.