Does H50.00 require prior authorization?

No, H50.00 does not require prior authorization (high confidence). Covered without prior authorization.

`H50.00`, Unspecified esotropia

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical records must document the exact type and strength of botulinum toxin used (Botox, Dysport, Xeomin, or Myobloc) and the dosage administered.
Medical records must include a covered diagnosis per the LCD (or a physician statement explaining use for an indication not listed in the AHFS) and support for clinical effectiveness of the injections.
Except for the enumerated exceptions (focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's cramp, laryngeal spasm, dysphonia), the record must state that traditional methods of treatment have been tried and proven unsuccessful.
The record must include a complete anatomic description of injection site(s) and support for the medical necessity of electromyography if EMG was used.

Botulinum toxin injections are covered when medical necessity is documented according to the Local Coverage Determination (LCD) 'Botulinum Toxin Types A and B' Indications and Limitations of Coverage.
Approved formulations include Botox (onabotulinumtoxinA), Dysport (abotulinumtoxinA), Xeomin (incobotulinumtoxinA), and Myobloc (rimabotulinumtoxinB); when a formulation is used for an indication not listed in the AHFS, a physician statement explaining the reason(s) for the unapproved form must be in the medical record.
Focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's cramp, laryngeal spasm, and dysphonia are recognized indications for which prior failure of traditional therapies is not required to document medical necessity.
Botulinum toxin injections are covered when the medical record documents medical necessity consistent with the associated LCD Botulinum Toxin Types A and B (L35172).
Covered botulinum toxin preparations include onabotulinumtoxinA (Botox), abobotulinumtoxinA (Dysport), incobotulinumtoxinA (Xeomin), and rimabotulinumtoxinB (Myobloc).
A statement that traditional methods of treatment have been tried and proven unsuccessful must be documented except for focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's cramp, laryngeal spasm, or dysphonia where such trials are not required.

CGS-J15-L39857, Botulinum Toxin Injections

J15

CGS-J15-L39856, Botulinum Toxin Injections

J15

CGS-J18-L39856, Botulinum Toxin Injections

J18

CGS-J18-L39857, Botulinum Toxin Injections

J18

WPS-J5-L40381

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