LCD ID Number: L33646 Status: A-Approved
LCD Title: Botulinum Toxins
Geographic Jurisdiction: Illinois Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
Revision Effective Date:
Revision End Date:
CMS National Coverage Policy:
Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:
Title XVIII of the Social Security Act (SSA):
Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Section 1862(a)(10) excludes coverage for cosmetic surgery.
Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Code of Federal Regulations:
42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements)who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 8:
50.5 Drugs and Biologicals [Coverage of SNF services]
70 Medical and Other Health Services Furnished to SNF Patients.
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 12:
40.9 Drugs and Biologicals [Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage]
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:
50.1–50.5 Drugs and Biologicals
260 Ambulatory Surgical Center Services
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16:
CMS Publication 100-04; Medicare Claims Processing Manual, Chapter 17:
40 Discarded Drugs and Biologicals
CMS Publication 100-04; Medicare Claims Processing Manual, Chapter 30:
20.2.1 Categorical Denials
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