Botulinum Toxins: Botox® (Onabotulinumtoxina), Dysport™ (Abobotulinumtoxina), Myobloc® (Rimabotulinumtoxin B), Xeomin® (Incobotulinumtoxina)

Botulinum Toxins: Botox® (onabotulinumtoxinA), Dysport™ (abobotulinumtoxinA), Myobloc® (rimabotulinumtoxin B), Xeomin® (incobotulinumtoxinA)

Last Review Date: 03/25/2014 Dates Reviewed: 09/2011, 12/2011, 03/2012, 06/19/2012, 09/06/2012, 12/06/2012, 02/07/2013, 03/07/2013, Date of Origin: 06/21/2011 06/06/2013, 09/05/2013, 12/05/2013, 03/25/2014 Prior Auth Available: √ Post-service edit: √ Medical Necessity Criteria Number: IC-0022 The medical necessity criteria were developed by ICORE Healthcare for the purpose of making clinical review determinations for requests for medications commonly used in various diseases. The clinical disciplines of oncology, hematology, rheumatology, neurology, internal medicine, pharmacy and nursing were consulted as part of the criteria development. The development followed an extensive literature search pertaining to established clinical guidelines and accepted prescribing patterns for each individual drug. The indications for the medications are consistent with FDA approved indications, CMS coverage guidelines, National Comprehensive Cancer Network (NCCN) guidelines and/or other published peer reviewed research literature.

I. Medication Description: OnabotulinumtoxinA (formerly known as botulinum toxin type A) is an intramuscular toxin produced from fermentation of Clostridium botulinum type A. It is one of seven toxic serotypes of botulinum (A through G) that have been purified. Two of the serotypes are available commercially in the United states, type A and type B. Type A toxins are more potent and longer-acting than type B. Patients who develop antibodies to type A toxins may benefit from type B toxin injections because there is no cross-reactivity between type A and type B toxins.

Botox (OnabotulinumtoxinA) blocks neuromuscular conduction by binding to receptor sites on motor nerve terminals, entering nerve terminals, and inhibiting the release of acetylcholine. After intramuscular injection of a therapeutic dose, onabotulinumtoxinA produces partial chemical denervation of the muscle resulting in a localized reduction in muscle activity. A reduction in sialorrhea may also occur by blocking the liberation of acetylcholine in autonomic nerve terminals in the parotid and submandibular glands.

Dysport (AbobotulinumtoxinA) inhibits release of the neurotransmitter, acetylcholine, from peripheral cholinergic nerve endings. Toxin activity occurs in the following sequence: toxin-heavy, chain-mediated binding to specific surface receptors on nerve ending; internalization of the toxin by receptor-mediated endocytosis; pH- induced translocation of the toxin light chain to the cell cytosol; and cleavage of SNAP25, leading to intracellular blockage of neurotransmitter exocytosis into the neuromuscular junction. This accounts for the therapeutic utility of the toxin in diseases characterized by excessive efferent activity in motor nerves.

Myobloc (Rimabotulinumtoxin B), a purified neurotoxin, acts at the neuromuscular junction to produce flaccid paralysis. The 7 serologically distinct botulinum neurotoxins, designated A through G, share a common structural organization consisting of 1 heavy chain and 1 light chain polypeptide linked by a single disulfide bond. These toxins inhibit acetylcholine release at the neuromuscular junction via a 3-stage process: 1) heavy chain– mediated neurospecific binding of the toxin, 2) internalization of the toxin by receptor-mediated endocytosis, 3) and ATP- and pH-dependent translocation of the light chain to the neuronal cytosol, where it acts as a zinc- dependent endoprotease cleaving polypeptides essential for neurotransmitter release.

Rimabotulinumtoxin B specifically has been demonstrated to cleave synaptic vesicle-associated membrane Page 1 of 107

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protein (VAMP, also known as synaptobrevin), which is a component of the protein complex responsible for docking and fusion of the synaptic vesicle to the presynaptic membrane, a necessary step for neurotransmitter release.

Xeomin (IncobotulinumtoxinA) blocks cholinergic transmission at the neuromuscular junction by inhibiting the release of acetylcholine from peripheral cholinergic nerve endings. This inhibition occurs according to the following sequence: neurotoxin binding to cholinergic nerve terminals, internalization of the neurotoxin into the nerve terminal, translocation of the light-chain part of the molecule into the cytosol of the nerve terminal, and enzymatic cleavage of SNAP25, a presynaptic target protein essential for the release of acetylcholine. Impulse transmission is reestablished by the formation of new nerve endings.

II. Length of Authorization: Coverage is provided for 6 months and may be renewed

III. Review Criteria: Coverage is provided in the following conditions:

Botox is considered medically necessary in the following (all indications are limited to patients age 18 or greater unless otherwise noted):

Blepharospasms: † o Age 12 or greater

Cervical dystonia: † o Patient age 16 or greater; AND o Patient has sustained head tilt; OR o Abdominalposturing with limited range of motion in neck; AND o History of recurrent involuntary contraction of one or more muscles in the neck

Strabismus† o Age 12 or greater

Upper limb spasticity†

Severe primary axillary hyperhidrosis: † o Patient has failed with topical agents; AND o Patient has failed or has contraindications to oral pharmacotherapy; AND o Patient has history of medical complications such as skin infections or significant functional impairments OR o Patient has had a significant impact to activities of daily living due to condition

Prophylaxis for chronic migraines: † o Patient has 15 or more migraine days per month with each migraine lasting 4 or more hours; AND o Patient has had chronic migraines for at least 6 months; AND o Patient has failed a 2 month or longer trial of two of the following oral medications:

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• Antidepressants (ex. amitriptyline, doxepin, nortriptyline) • Beta blockers (ex.atenolol, propranolol) • Angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (ex. lisinopril, candesartan) • Anti-epileptics (ex. valproate, topiramate) • Calcium channels blockers (ex. nifedipine, verapamil)

Esophageal achalasia o Patient is at high risk of complication from pneumatic dilation or surgical myotomy; OR o Patient has had treatment failure with pneumatic dilation or surgical myotomy; OR o Patient has had perforation from pneumatic dilation; OR o Patient has an epiphrenic diverticulum or hiatal hernia ;OR o Patient has esophageal varices

Oromandibular dystonia

Laryngeal dystonia

Cerebral palsy with concurrent equinus gait

Sialorrhea associated with neurological disorders: o Patient has Parkinson’s disease; OR o Patient has severe developmental delays; AND o Patient has failed oral therapy ; OR o Patient has cerebral palsy; AND o Patient has failed oral therapy

Incontinence due to detrusor overreactivity† o Patient has failed therapy with anticholinergics

Overactive bladder (OAB)† o Patient has symptoms of urge urinary incontinence, urgency, and frequency; AND o Patient has failed therapy with anticholinergics

Hyperhidrosis, palmer

Focal upper limb dystonia: o Patient has functional impairment; OR o Patient has pain as a result

Idiopathic (primary or genetic) torsion and symptomatic (acquired) torsion dystonia

Hereditary spastic paraplegia

Infantile cerebral palsy

Spasticity due to multiple sclerosis

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Neuromyelitis optica

Schilder’s disease

Spastic hemiplegia

Chronic anal fissure o Patient has failed conventional therapy

Idiopathic tranverse myelitis

Quadriplegia

Paraplegia

Diplegia of upper limbs

Monoplegia

Spastic ENT/Ectropion

Hemiplegia

Other paralytic syndromes

Hemifacial Spasm

Dysport is considered medically necessary in the following: Cervical dystonia: † o Patient age 18 or greater; AND o Patient has sustained head tilt; OR o Abdominalposturing with limited range of motion in neck; AND o History of recurrent involuntary contraction of one or more muscles in the neck

Myobloc is considered medically necessary in the following: Cervical dystonia: † o Patient age 18 or greater; AND o Patient has sustained head tilt; OR o Abdominalposturing with limited range of motion in neck; AND o History of recurrent involuntary contraction of one or more muscles in the neck

Xeomin is considered medically necessary in the following: Cervical dystonia† o Patient age 18 or greater; AND o Patient has sustained head tilt; OR o Abdominalposturing with limited range of motion in neck; AND o History of recurrent involuntary contraction of one or more muscles in the neck

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Blepharospasms† o Patient age 18 or greater

†FDA Approved Indication(s)

IV. Renewal Criteria: Coverage can be renewed based upon the following criteria: o Patient continues to meet criteria identified in section III; AND o Disease response; AND o Absence of unacceptable toxicity from the drug o Botox - For Headache/Migraine: o Significant decrease in number and frequency of headaches; AND o Improvement in function

V. Dosage/Administration: Botox Indication Dose Blepharospasm 1.25-2.5 Units (0.05—0.1 ml per site) injected into each of 3 sites per affected eye every three months. Cumulative dose in 30 days should not exceed 200 units Cervical Dystonia 198 Units to 300 Units divided among the affected muscles. No more than 50 Units per site. Strabismus Based on muscle(s) affected, 1.25-2.5 Units in any one muscle. No more than 25 Units in any one muscle for recurrent cases Achalasia 100 Units (20-25 Units per quadrant) per administration Upper Limb Spasticity Varies by site of action, general rule is no more than 50 Units per site, no sooner than every 12 weeks. Chronic Migraine 155 Units administered intramuscularly (IM) as 0.1 mL (5 Units) injections per each site. Injections should be divided across 7 specific head/neck muscle areas. Focal Spasticity 4 Units/kg IM (up to 200 Units) divided into 2 injections in the (cerebral palsy patients, ages 2- affected leg every 3 months 18 years) Servere primary axillary 50 Units intradermally per axilla every 4 months hyperhidrosis Sialorrhea 15-40 Units in the parotid gland injected in two places and 10- 15 Units in the submandibular glands (total dose from 50-100 Units per patient/administration). Neurogenic bladder 200 Units per treatment injected into the detrusor muscle using 30 injections (6.7 units each). Overactive Bladder (OAB) 100 Units per treatment injected into the detrusor muscle using 20 injections (5 units each).

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Dysport Indication Dose Cervical Dystonia Initial dose: 500 units divided among the affected muscles. Re-treatment: 250-1000 every 12 -16 weeks or longer as necessary

Myobloc Indication Dose Cervical Dystonia Initial dose: 2,500 – 5,000 units divided among the affected muscles. Re-treatment: 2,500-10,000 units every 12 - 16 weeks or longer, as necessary

Xeomin Indication Dose Cervical Dystonia 120 units divided among the affected muscles every 12 weeks or longer, as necessary Blepharospasm 1.25 – 5.6 units per injection site, not to exceed 35 units per eye, every 12 weeks or longer, as necessary

VI. Billing/Code Information: JCode: J0585 – Botox (Allergan, Inc) 100 units, 200 units, Injection: 1 billable unit = 1 unit J0586 – Dysport (Medicis) 300 units, 500 units, Injection: 1 billable unit = 5 units J0587 – Myobloc (Solstice Neurosciences) 2,500 units, 5,000 units, 10,000 units Injection: 1 billable unit = 100 units J0588 – Xeomin (Merz GmbH) 50 units, 100 units Injection: 1 billable unit = 1 unit

Botox (J0585) Max Units (per dose and over time): Male: 360 billable units per 12 weeks (84 days) Female: 360 billable units per 12 weeks (84 days)

Dysport (J0586) Max Units (per dose and over time): Male: 200 billable units per 12 weeks (84 days) Female: 200 billable units per 12 weeks (84 days)

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Myobloc (J0587) Max Units (per dose and over time): Male: 100 billable units per 12 weeks (84 days) Female: 100 billable units per 12 weeks (84 days)

Xeomin (J0588) Max Units (per dose and over time): Male: 120 billable units per 12 weeks (84 days) Female: 120 billable units per 12 weeks (84 days)

Covered Diagnosis: Botox (J0585) ICD-9 Codes Diagnosis 333.6 Genetic torsion dystonia 333.79 Other acquired torsion dystonia 333.81 Blepharospasm 333.82 Orofacial dyskinesia 333.83 Spasmodic torticollis 333.89 Other fragments of torsion dystonia 333.71 Athetoid cerebral palsy 333.84 Organic writers' cramp 334.1 Hereditary spastic paraplegia 339.12 Chronic tension type headache 340 Multiple sclerosis 341.0 Neuromyelitis optica 341.1 Schilder's disease 341.22 Idiopathic transverse myelitis 341.8 Other demyelinating diseases of central nervous system 342.10 Spastic hemiplegia and hemiparesis affecting unspecified side 342.11 Spastic hemiplegia and hemiparesis affecting dominant side 342.12 Spastic hemiplegia and hemiparesis affecting nondominant side 343.0 Congenital diplegia 343.1 Congenital hemiplegia 343.2 Congenital quadriplegia 343.4 Infantile hemiplegia 343.8 Other specified infantile cerebral palsy 343.9 Infantile cerebral palsy, unspecified 344.00 Quadriplegia, unspecified 344.01 Quadriplegia, C1-C4, complete 344.02 Quadriplegia, C1-C4, incomplete 344.03 Quadriplegia, C5-C7, complete Page 7 of 107

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344.04 Quadriplegia, C5-C7, incomplete 344.09 Other quadriplegia 344.1 Paraplegia 344.2 Diplegia of upper limbs 344.30 Monoplegia of lower limb affecting unspecified side 344.31 Monoplegia of lower limb affecting dominant side 344.32 Monoplegia of lower limb affecting nondominant side 344.40 Monoplegia of upper limb affecting unspecified side 344.41 Monoplegia of upper limb affecting dominant side 344.42 Monoplegia of upper limb affecting nondominant sde 344.61 Cauda equina syndrome with neurogenic bladder 346.01 Migraine with aura, with intractable migraine, so stated, without mention of status migrainosus 346.11 Migraine without aura, with intractable migraine, so stated, without mention of status migrainosus 346.90 Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus 346.91 Migraine, unspecified, with intractable migraine, so stated, without mention of status migrainosus 346.92 Migraine, unspecified, without mention of intractable migraine with status migrainosus 346.93 Migraine, unspecified, with intractable migraine, so stated, with status migrainosus 351.8 Other facial nerve disorders 374.03 Spastic entropion 374.13 Spastic ectropion 378.00 Esotropia, unspecified 378.01 Monocular esotropia 378.02 Monocular esotropia with A pattern 378.03 Monocular esotropia with V pattern 378.04 Monocular esotropia with other noncomitancies 378.05 Alternating esotropia 378.06 Alternating esotropia with A pattern 378.07 Alternating esotropia with V pattern 378.08 Alternating esotropia with other noncomitancies 378.10 Exotropia, unspecified 378.11 Monocular exotropia 378.12 Monocular exotropia with A pattern 378.13 Monocular exotropia with V pattern 378.14 Monocular exotropia with other noncomitancies

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378.15 Alternating exotropia 378.16 Alternating exotropia with A pattern 378.17 Alternating exotropia with V pattern 378.18 Alternating exotropia with other noncomitancies 378.20 Intermittent heterotropia, unspecified 378.21 Intermittent esotropia, monocular 378.22 Intermittent esotropia, alternating 378.23 Intermittent exotropia, monocular 378.24 Intermittent exotropia, alternating 378.30 Heterotropia, unspecified 378.31 Hypertropia 378.32 Hypotropia 378.33 Cyclotropia 378.34 Monofixation syndrome 378.35 Accommodative component in esotropia 378.40 Heterophoria, unspecified 378.41 Esophoria 378.42 Exophoria 378.43 Vertical heterophoria 378.44 Cyclophoria 378.45 Alternating hyperphoria 378.50 Paralytic strabismus, unspecified 378.51 Third or oculomotor nerve palsy, partial 378.52 Third or oculomotor nerve palsy, total 378.53 Fourth or trochlear nerve palsy 378.54 Sixth or abducens nerve palsy 378.55 External ophthalmoplegia 378.56 Total ophthalmoplegia 378.60 Mechanical strabismus, unspecified 378.61 Brown's (tendon) sheath syndrome 378.62 Mechanical strabismus from other musculofascial disorders 378.63 Limited duction associated with other conditions 378.71 Duane's syndrom 378.72 Progressive external ophthalmoplegia 378.73 Strabismus in other neuromuscular disorders 378.81 Palsy of conjugate gaze 378.82 Spasm of conjugate gaze 378.83 Convergence insufficiency or palsy 378.84 Convergence excess or spasm 378.85 Anomalies of divergence

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378.86 Internuclear ophthalmoplegia 378.87 Other dissociated deviation of eye movements 378.9 Unspecified disorder of eye movements 478.75 Laryngeal spasm 527.7 Disturbance of salivary secretion 530.0 Achalasia and cardiospasm 565.0 Anal fissure 596.51 Hypertonicity of bladder 596.52 Low bladder compliance 596.54 Neurogenic bladder NOS 596.55 Detrusor sphincter dyssynergia 705.21 Primary focal hyperhidrosis 705.22 Secondary focal hyperhidrosis 723.5 Torticollis, unspecified 728.85 Spasm of muscle 788.31 Urge incontinence 788.33 Mixed incontinence (male) (female) 788.41 Urinary frequency

Dysport (J0586) ICD-9 Codes Diagnosis 333.83 Spasmodic torticollis 723.5 Torticollis, unspecified

Myobloc (J0587) ICD-9 Codes Diagnosis 333.83 Spasmodic torticollis 723.5 Torticollis, unspecified

Xeomin (J0588) ICD-9 Codes Diagnosis 333.81 Blepharospasm 333.83 Spasmodic torticollis 723.5 Torticollis, unspecified

VII. Centers for Medicare and Medicaid Services (CMS): Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD) and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.

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Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD): Botox (J0585) Jurisdiction(s): 10 (J) NCD/LCD Document (s): L30025 ICD-9 Codes Diagnosis 333.6 GENETIC TORSION DYSTONIA 333.71 ATHETOID CEREBRAL PALSY 333.79 OTHER ACQUIRED TORSION DYSTONIA 333.81 – 333.85 BLEPHAROSPASM - SUBACUTE DYSKINESIA DUE TO DRUGS 333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE ACUTE (TRANSVERSE) MYELITIS NOS - IDIOPATHIC TRANSVERSE 341.20 – 341.22 MYELITIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - 342.10 – 342.12 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 343.0 - 343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 – 344.5 QUADRIPLEGIA UNSPECIFIED - UNSPECIFIED MONOPLEGIA CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS 346.70 – 346.73 - CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS 351.8 OTHER FACIAL NERVE DISORDERS ESOTROPIA UNSPECIFIED - ALTERNATING ESOTROPIA WITH OTHER 378.00 – 378.08 NONCOMITANCIES EXOTROPIA UNSPECIFIED - ALTERNATING EXOTROPIA WITH OTHER 378.10 – 378.18 NONCOMITANCIES INTERMITTENT HETEROTROPIA UNSPECIFIED - INTERMITTENT 378.20 – 378.24 EXOTROPIA ALTERNATING HETEROTROPIA UNSPECIFIED - ACCOMMODATIVE COMPONENT IN 378.30 – 378.35 ESOTROPIA 378.40 – 378.45 HETEROPHORIA UNSPECIFIED - ALTERNATING HYPERPHORIA PARALYTIC STRABISMUS UNSPECIFIED - SIXTH OR ABDUCENS NERVE 378.50 – 378.54 PALSY MECHANICAL STRABISMUS UNSPECIFIED - LIMITED DUCTION 378.60 – 378.63 ASSOCIATED WITH OTHER CONDITIONS Page 11 of 107

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378.71 DUANE'S SYNDROME 378.81 – 378.85 PALSY OF CONJUGATE GAZE - ANOMALIES OF DIVERGENCE 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING 438.20 – 438.22 NONDOMINANT SIDE MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE - 438.30 – 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - 438.40 – 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 564.6 ANAL SPASM 565.0 ANAL FISSURE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 705.22 SECONDARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE CONGENITAL MUSCULOSKELETAL DEFORMITIES OF 754.1 STERNOCLEIDOMASTOID MUSCLE 780.8 GENERALIZED HYPERHIDROSIS 784.40 – 784.42 VOICE AND RESONANCE DISORDER, UNSPECIFIED - DYSPHONIA 784.49 OTHER VOICE AND RESONANCE DISORDERS 788.31 URGE INCONTINENCE V72.85 OTHER SPECIFIED EXAMINATION

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333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 339.02 CHRONIC CLUSTER HEADACHE 339.12 CHRONIC TENSION TYPE HEADACHE 340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE 341.22 IDIOPATHIC TRANSVERSE MYELITIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED 342.10 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5 UNSPECIFIED MONOPLEGIA MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS - MIGRAINE WITH AURA, 346.01 - 346.03 WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS

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MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.11 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.13 WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.21 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.23 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.31 WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.33 WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.41 WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.43 WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.51 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.53 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.61 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.63 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.81 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.83 STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.90 MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.91 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.92 MIGRAINE WITH STATUS MIGRAINOSUS

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MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 350.9 TRIGEMINAL NERVE DISORDER UNSPECIFIED 351.8 OTHER FACIAL NERVE DISORDERS 351.9 FACIAL NERVE DISORDER UNSPECIFIED 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA

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378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME 378.62 MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL 478.31 PARTIAL UNILATERAL PARALYSIS OF VOCAL CORDS 478.33 PARTIAL BILATERAL PARALYSIS OF VOCAL CORDS 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE

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596.51 HYPERTONICITY OF BLADDER 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE 784.42 DYSPHONIA 788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE)

Jurisdiction(s): 9 (N) NCD/LCD Document (s): L29088; L29103 ICD-9 Codes Diagnosis 333.6 GENETIC TORSION DYSTONIA 333.71 ATHETOID CEREBRAL PALSY 333.79 OTHER ACQUIRED TORSION DYSTONIA 333.81 BLEPHAROSPASM 333.82 OROFACIAL DYSKINESIA 333.83 SPASMODIC TORTICOLLIS 333.84 ORGANIC WRITERS' CRAMP 333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 340 MULTIPLE SCLEROSIS NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL 341.0 - 341.9 NERVOUS SYSTEM UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE - 342.11 - 342.12 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 - 344.09 QUADRIPLEGIA UNSPECIFIED - OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - 344.30 - 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE - 344.40 - 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE

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344.5 UNSPECIFIED MONOPLEGIA CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS 351.8 OTHER FACIAL NERVE DISORDERS ESOTROPIA UNSPECIFIED - UNSPECIFIED DISORDER OF EYE 378.00 - 378.9 MOVEMENTS 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.41 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 478.75 LARYNGEAL SPASM 478.79 OTHER DISEASES OF LARYNX 530.0 ACHALASIA AND CARDIOSPASM 564.6 ANAL SPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 596.59 OTHER FUNCTIONAL DISORDER OF BLADDER 705.21 PRIMARY FOCAL HYPERHIDROSIS 705.22 SECONDARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE)

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339.12 CHRONIC TENSION TYPE HEADACHE 340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE 341.22 IDIOPATHIC TRANSVERSE MYELITIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM 341.9 UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED 342.10 SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.01 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.11 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS 346.70 CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF

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INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.90 MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.91 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.92 MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 351.8 OTHER FACIAL NERVE DISORDERS 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING

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378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL 378.62 DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE

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438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.52 LOW BLADDER COMPLIANCE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE

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MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.11 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.13 WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.70 INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS 350.8 OTHER SPECIFIED TRIGEMINAL NERVE DISORDERS 351.8 OTHER FACIAL NERVE DISORDERS 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION 375.21 EPIPHORA DUE TO EXCESS LACRIMATION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA

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378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME 378.62 MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 478.29 OTHER DISEASES OF PHARYNX OR NASOPHARYNX 478.75 LARYNGEAL SPASM 478.79 OTHER DISEASES OF LARYNX 527.7 DISTURBANCE OF SALIVARY SECRETION 529.8 OTHER SPECIFIED CONDITIONS OF THE TONGUE 530.0 ACHALASIA AND CARDIOSPASM 530.89 OTHER DISEASES OF ESOPHAGUS 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.52 LOW BLADDER COMPLIANCE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 596.59 OTHER FUNCTIONAL DISORDER OF BLADDER 596.89 OTHER SPECIFIED DISORDERS OF BLADDER 705.21 PRIMARY FOCAL HYPERHIDROSIS 705.22 SECONDARY FOCAL HYPERHIDROSIS 728.85* SPASM OF MUSCLE 784.49 OTHER VOICE AND RESONANCE DISORDERS

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788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE) 788.39 OTHER URINARY INCONTINENCE Secondary Codes Must be used along with ICD-9 code 728.85 340* MULTIPLE SCLEROSIS 342.11* SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12* SIDE 343.8* OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9* INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00* QUADRIPLEGIA UNSPECIFIED 344.01* QUADRIPLEGIA C1-C4 COMPLETE 344.02* QUADRIPLEGIA C1-C4 INCOMPLETE 344.03* QUADRIPLEGIA C5-C7 COMPLETE 344.04* QUADRIPLEGIA C5-C7 INCOMPLETE 344.09* OTHER QUADRIPLEGIA 344.1* PARAPLEGIA 344.2* DIPLEGIA OF UPPER LIMBS 344.30* MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31* MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32* MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40* MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41* MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42* MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5* UNSPECIFIED MONOPLEGIA 344.60* CAUDA EQUINA SYNDROME WITHOUT NEUROGENIC BLADDER 430* SUBARACHNOID HEMORRHAGE 431* INTRACEREBRAL HEMORRHAGE 432.0* NONTRAUMATIC EXTRADURAL HEMORRHAGE 432.1* SUBDURAL HEMORRHAGE OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL 433.01* INFARCTION OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL 433.11* INFARCTION OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL 433.21* INFARCTION OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL 433.31* ARTERIES WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY 433.81* WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY 433.91* WITH CEREBRAL INFARCTION 434.01* CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION 434.11* CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL 434.91* INFARCTION

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438.21* HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22* HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.31* MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32* MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.41* MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 438.42* MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.51* OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52* OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53* OTHER PARALYTIC SYNDROME BILATERAL 952.00* C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.01* C1-C4 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.02* C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME 952.03* C1-C4 LEVEL WITH CENTRAL CORD SYNDROME 952.04* C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.05* C5-C7 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.06* C5-C7 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.07* C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME 952.08* C5-C7 LEVEL WITH CENTRAL CORD SYNDROME 952.09* C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.10* T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.11* T1-T6 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.12* T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME 952.13* T1-T6 LEVEL WITH CENTRAL CORD SYNDROME 952.14* T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.15* T7-T12 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.16* T7-T12 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.17* T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME 952.18* T7-T12 LEVEL WITH CENTRAL CORD SYNDROME 952.19* T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 997.01* CENTRAL NERVOUS SYSTEM COMPLICATION 997.02* IATROGENIC CEREBROVASCULAR INFARCTION OR HEMORRHAGE

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341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS 346.70 - 346.73 - CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS 350.8 OTHER SPECIFIED TRIGEMINAL NERVE DISORDERS 351.8 OTHER FACIAL NERVE DISORDERS 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA

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378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME 378.62 MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 478.29 OTHER DISEASES OF PHARYNX OR NASOPHARYNX 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.52 LOW BLADDER COMPLIANCE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA

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705.21 PRIMARY FOCAL HYPERHIDROSIS 705.22 SECONDARY FOCAL HYPERHIDROSIS 728.85* SPASM OF MUSCLE 784.49 OTHER VOICE AND RESONANCE DISORDERS 788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE) 788.41 URINARY FREQUENCY Secondary Codes Must be used along with ICD-9 code 728.85 340* MULTIPLE SCLEROSIS 342.11* SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12* SIDE 344.1* PARAPLEGIA 344.2* DIPLEGIA OF UPPER LIMBS 344.5* UNSPECIFIED MONOPLEGIA 430* SUBARACHNOID HEMORRHAGE 431* INTRACEREBRAL HEMORRHAGE 432.0* NONTRAUMATIC EXTRADURAL HEMORRHAGE 432.1* SUBDURAL HEMORRHAGE OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL 433.01* INFARCTION OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL 433.11* INFARCTION OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL 433.21* INFARCTION OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL 433.31* ARTERIES WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY 433.81* WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY 433.91* WITH CEREBRAL INFARCTION 434.01* CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION 434.11* CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL 434.91* INFARCTION 438.21* HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22* HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.31* MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32* MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.41* MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE

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438.42* MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.51* OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52* OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53* OTHER PARALYTIC SYNDROME BILATERAL 952.00* C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.01* C1-C4 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.02* C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME 952.03* C1-C4 LEVEL WITH CENTRAL CORD SYNDROME 952.04* C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.05* C5-C7 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.06* C5-C7 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.07* C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME 952.08* C5-C7 LEVEL WITH CENTRAL CORD SYNDROME 952.09* C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.10* T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.11* T1-T6 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.12* T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME 952.13* T1-T6 LEVEL WITH CENTRAL CORD SYNDROME 952.14* T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.15* T7-T12 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.16* T7-T12 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.17* T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME 952.18* T7-T12 LEVEL WITH CENTRAL CORD SYNDROME 952.19* T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 997.01* CENTRAL NERVOUS SYSTEM COMPLICATION 997.02* IATROGENIC CEREBROVASCULAR INFARCTION OR HEMORRHAGE

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334.1 HEREDITARY SPASTIC PARAPLEGIA 339.02 CHRONIC CLUSTER HEADACHE 339.12 CHRONIC TENSION TYPE HEADACHE 340 MULTIPLE SCLEROSIS NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL 341.0 - 341.9 NERVOUS SYSTEM UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.10 - 342.12 - SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 343.0 - 343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 - 344.5 QUADRIPLEGIA UNSPECIFIED - UNSPECIFIED MONOPLEGIA 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.01 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITH AURA, WITHOUT MENTION OF INTRACTABLE 346.02 MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.03 WITH STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.11 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.13 STATED, WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.21 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.23 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.31 WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.33 WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.41 WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.43 WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.51 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.53 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS

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PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.61 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.63 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS 346.70 - 346.73 MIGRAINOSUS - CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.81 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.83 STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.91 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 350.9 TRIGEMINAL NERVE DISORDER UNSPECIFIED OTHER FACIAL NERVE DISORDERS - FACIAL NERVE DISORDER 351.8 - 351.9 UNSPECIFIED 374.03 SPASTIC ENTROPION ESOTROPIA UNSPECIFIED - UNSPECIFIED DISORDER OF EYE 378.00 - 378.9 MOVEMENTS MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE - 438.31 - 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 478.31 PARTIAL UNILATERAL PARALYSIS OF VOCAL CORDS 478.33 PARTIAL BILATERAL PARALYSIS OF VOCAL CORDS 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.52 LOW BLADDER COMPLIANCE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE 729.82 CRAMP OF LIMB

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784.42 DYSPHONIA 788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE) 788.41 URINARY FREQUENCY

Jurisdiction(s): 5, 8 NCD/LCD Document (s): L28555 ICD-9 Codes Diagnosis 332.0 PARALYSIS AGITANS 333.1 ESSENTIAL AND OTHER SPECIFIED FORMS OF TREMOR 333.3 TICS OF ORGANIC ORIGIN 333.6 GENETIC TORSION DYSTONIA 333.71 ATHETOID CEREBRAL PALSY 333.72 ACUTE DYSTONIA DUE TO DRUGS 333.79 OTHER ACQUIRED TORSION DYSTONIA 333.81 BLEPHAROSPASM 333.82 OROFACIAL DYSKINESIA 333.83 SPASMODIC TORTICOLLIS 333.84 ORGANIC WRITERS' CRAMP 333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED 342.10 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE Page 33 of 107

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344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5 UNSPECIFIED MONOPLEGIA 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.70 INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS 351.8 OTHER FACIAL NERVE DISORDERS 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION ESOTROPIA UNSPECIFIED - ALTERNATING ESOTROPIA WITH OTHER 378.00 - 378.08 NONCOMITANCIES EXOTROPIA UNSPECIFIED - ALTERNATING EXOTROPIA WITH OTHER 378.10 - 378.18 NONCOMITANCIES INTERMITTENT HETEROTROPIA UNSPECIFIED - INTERMITTENT 378.20 - 378.24 EXOTROPIA ALTERNATING HETEROTROPIA UNSPECIFIED - ACCOMMODATIVE COMPONENT IN 378.30 - 378.35 ESOTROPIA 378.40 - 378.45 HETEROPHORIA UNSPECIFIED - ALTERNATING HYPERPHORIA 378.50 - 378.56 PARALYTIC STRABISMUS UNSPECIFIED - TOTAL OPHTHALMOPLEGIA MECHANICAL STRABISMUS UNSPECIFIED - LIMITED DUCTION 378.60 - 378.63 ASSOCIATED WITH OTHER CONDITIONS 378.71 - 378.73 DUANE'S SYNDROME - STRABISMUS IN OTHER NEUROMUSCULAR

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DISORDERS PALSY OF CONJUGATE GAZE - OTHER DISSOCIATED DEVIATION OF EYE 378.81 - 378.87 MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.0 COGNITIVE DEFICITS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.41 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL UNSPECIFIED PARALYSIS OF VOCAL CORDS - COMPLETE BILATERAL 478.30 - 478.34 PARALYSIS OF VOCAL CORDS 478.75 LARYNGEAL SPASM 527.2 SIALOADENITIS 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 596.59 OTHER FUNCTIONAL DISORDER OF BLADDER

705.21 PRIMARY FOCAL HYPERHIDROSIS

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784.51 DYSARTHRIA 784.52 FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE 784.59 OTHER SPEECH DISTURBANCE 788.31 URGE INCONTINENCE 788.41 URINARY FREQUENCY

Dysport (J0586)

Jurisdiction(s): 10 (J) NCD/LCD Document (s): L30025 ICD-9 Codes Diagnosis 333.6 GENETIC TORSION DYSTONIA 333.71 ATHETOID CEREBRAL PALSY 333.79 OTHER ACQUIRED TORSION DYSTONIA 333.81 – 333.85 BLEPHAROSPASM - SUBACUTE DYSKINESIA DUE TO DRUGS 333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE ACUTE (TRANSVERSE) MYELITIS NOS - IDIOPATHIC TRANSVERSE 341.20 – 341.22 MYELITIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - 342.10 – 342.12 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 343.0 - 343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 – 344.5 QUADRIPLEGIA UNSPECIFIED - UNSPECIFIED MONOPLEGIA CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS 346.70 – 346.73 - CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS 351.8 OTHER FACIAL NERVE DISORDERS ESOTROPIA UNSPECIFIED - ALTERNATING ESOTROPIA WITH OTHER 378.00 – 378.08 NONCOMITANCIES EXOTROPIA UNSPECIFIED - ALTERNATING EXOTROPIA WITH OTHER 378.10 – 378.18 NONCOMITANCIES INTERMITTENT HETEROTROPIA UNSPECIFIED - INTERMITTENT 378.20 – 378.24 EXOTROPIA ALTERNATING 378.30 – 378.35 HETEROTROPIA UNSPECIFIED - ACCOMMODATIVE COMPONENT IN

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ESOTROPIA 378.40 – 378.45 HETEROPHORIA UNSPECIFIED - ALTERNATING HYPERPHORIA PARALYTIC STRABISMUS UNSPECIFIED - SIXTH OR ABDUCENS NERVE 378.50 – 378.54 PALSY MECHANICAL STRABISMUS UNSPECIFIED - LIMITED DUCTION 378.60 – 378.63 ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.81 – 378.85 PALSY OF CONJUGATE GAZE - ANOMALIES OF DIVERGENCE 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING 438.20 – 438.22 NONDOMINANT SIDE MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE - 438.30 – 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - 438.40 – 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 564.6 ANAL SPASM 565.0 ANAL FISSURE 705.21 PRIMARY FOCAL HYPERHIDROSIS 705.22 SECONDARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE CONGENITAL MUSCULOSKELETAL DEFORMITIES OF 754.1 STERNOCLEIDOMASTOID MUSCLE 780.8 GENERALIZED HYPERHIDROSIS 784.40 – 784.42 VOICE AND RESONANCE DISORDER, UNSPECIFIED - DYSPHONIA 784.49 OTHER VOICE AND RESONANCE DISORDERS V72.85 OTHER SPECIFIED EXAMINATION

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333.82 OROFACIAL DYSKINESIA 333.83 SPASMODIC TORTICOLLIS 333.84 ORGANIC WRITERS' CRAMP 333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 339.02 CHRONIC CLUSTER HEADACHE 339.12 CHRONIC TENSION TYPE HEADACHE 340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE 341.22 IDIOPATHIC TRANSVERSE MYELITIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED 342.10 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5 UNSPECIFIED MONOPLEGIA 346.01 - 346.03 MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED,

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WITHOUT MENTION OF STATUS MIGRAINOSUS - MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.11 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.13 WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.21 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.23 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.31 WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.33 WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.41 WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.43 WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.51 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.53 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.61 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.63 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.81 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.83 STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.90 MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS 346.91 MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED,

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WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.92 MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 350.9 TRIGEMINAL NERVE DISORDER UNSPECIFIED 351.8 OTHER FACIAL NERVE DISORDERS 351.9 FACIAL NERVE DISORDER UNSPECIFIED 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED

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378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME 378.62 MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL 478.31 PARTIAL UNILATERAL PARALYSIS OF VOCAL CORDS 478.33 PARTIAL BILATERAL PARALYSIS OF VOCAL CORDS 478.75 LARYNGEAL SPASM

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527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE 784.42 DYSPHONIA 788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE)

Jurisdiction(s): 9 (N) NCD/LCD Document (s): L29088; L29103 ICD-9 Codes Diagnosis 333.81 BLEPHAROSPASM 333.82 OROFACIAL DYSKINESIA 333.83 SPASMODIC TORTICOLLIS 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED

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340 MULTIPLE SCLEROSIS NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL 341.0 - 341.9 NERVOUS SYSTEM UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.10 - 342.12 - SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 343.0 - 343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 - 344.5 QUADRIPLEGIA UNSPECIFIED - UNSPECIFIED MONOPLEGIA MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.01 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITH AURA, WITHOUT MENTION OF INTRACTABLE 346.02 MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.03 WITH STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.11 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.13 STATED, WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.21 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.23 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.31 WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.33 WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.41 WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.43 WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.51 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.53 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.61 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.63 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS Page 43 of 107

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OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.81 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.83 STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.91 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 350.9 TRIGEMINAL NERVE DISORDER UNSPECIFIED OTHER FACIAL NERVE DISORDERS - FACIAL NERVE DISORDER 351.8 - 351.9 UNSPECIFIED 374.03 SPASTIC ENTROPION ESOTROPIA UNSPECIFIED - UNSPECIFIED DISORDER OF EYE 378.00 - 378.9 MOVEMENTS MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE - 438.31 - 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 478.31 PARTIAL UNILATERAL PARALYSIS OF VOCAL CORDS 478.33 PARTIAL BILATERAL PARALYSIS OF VOCAL CORDS 478.75 LARYNGEAL SPASM 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE 729.82 CRAMP OF LIMB 784.42 DYSPHONIA

Botulinum Toxins Medical Necessity Criteria Last Review Date: 03/25/2014 Number: IC-0022

340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE 341.22 IDIOPATHIC TRANSVERSE MYELITIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM 341.9 UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED 342.10 SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.01 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.11 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.70 INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS

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MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.90 MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.91 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.92 MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 351.8 OTHER FACIAL NERVE DISORDERS 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR

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378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL 378.62 DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE

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438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.52 LOW BLADDER COMPLIANCE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE

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MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.11 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.13 WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.70 INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS 350.8 OTHER SPECIFIED TRIGEMINAL NERVE DISORDERS 351.8 OTHER FACIAL NERVE DISORDERS 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION 375.21 EPIPHORA DUE TO EXCESS LACRIMATION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA

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333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED 342.10 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5 UNSPECIFIED MONOPLEGIA 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.70 INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS 346.71 CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE,

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SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS 351.8 OTHER FACIAL NERVE DISORDERS 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION ESOTROPIA UNSPECIFIED - ALTERNATING ESOTROPIA WITH OTHER 378.00 - 378.08 NONCOMITANCIES EXOTROPIA UNSPECIFIED - ALTERNATING EXOTROPIA WITH OTHER 378.10 - 378.18 NONCOMITANCIES INTERMITTENT HETEROTROPIA UNSPECIFIED - INTERMITTENT 378.20 - 378.24 EXOTROPIA ALTERNATING HETEROTROPIA UNSPECIFIED - ACCOMMODATIVE COMPONENT IN 378.30 - 378.35 ESOTROPIA 378.40 - 378.45 HETEROPHORIA UNSPECIFIED - ALTERNATING HYPERPHORIA 378.50 - 378.56 PARALYTIC STRABISMUS UNSPECIFIED - TOTAL OPHTHALMOPLEGIA MECHANICAL STRABISMUS UNSPECIFIED - LIMITED DUCTION 378.60 - 378.63 ASSOCIATED WITH OTHER CONDITIONS DUANE'S SYNDROME - STRABISMUS IN OTHER NEUROMUSCULAR 378.71 - 378.73 DISORDERS PALSY OF CONJUGATE GAZE - OTHER DISSOCIATED DEVIATION OF EYE 378.81 - 378.87 MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.0 COGNITIVE DEFICITS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.41 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL 478.30 - 478.34 UNSPECIFIED PARALYSIS OF VOCAL CORDS - COMPLETE BILATERAL

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PARALYSIS OF VOCAL CORDS 478.75 LARYNGEAL SPASM 527.2 SIALOADENITIS 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 596.59 OTHER FUNCTIONAL DISORDER OF BLADDER

705.21 PRIMARY FOCAL HYPERHIDROSIS

723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE 729.89 OTHER MUSCULOSKELETAL SYMPTOMS REFERABLE TO LIMBS CONGENITAL MUSCULOSKELETAL DEFORMITIES OF 754.1 STERNOCLEIDOMASTOID MUSCLE 781.0 ABNORMAL INVOLUNTARY MOVEMENTS VOICE AND RESONANCE DISORDER, UNSPECIFIED - OTHER VOICE AND 784.40 - 784.49 RESONANCE DISORDERS 784.51 DYSARTHRIA 784.52 FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE 784.59 OTHER SPEECH DISTURBANCE 788.31 URGE INCONTINENCE 788.41 URINARY FREQUENCY

Myobloc (J0587)

Jurisdiction(s): 10 (J) NCD/LCD Document (s): L30025 ICD-9 Codes Diagnosis 333.83 SPASMODIC TORTICOLLIS 723.5 TORTICOLLIS UNSPECIFIED CONGENITAL MUSCULOSKELETAL DEFORMITIES OF 754.1 STERNOCLEIDOMASTOID MUSCLE

Jurisdiction(s): 15 NCD/LCD Document (s): L31855 ICD-9 Codes Diagnosis 307.81 TENSION HEADACHE 333.6 GENETIC TORSION DYSTONIA

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333.71 ATHETOID CEREBRAL PALSY 333.72 ACUTE DYSTONIA DUE TO DRUGS 333.79 OTHER ACQUIRED TORSION DYSTONIA 333.81 BLEPHAROSPASM 333.82 OROFACIAL DYSKINESIA 333.83 SPASMODIC TORTICOLLIS 333.84 ORGANIC WRITERS' CRAMP 333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 339.02 CHRONIC CLUSTER HEADACHE 339.12 CHRONIC TENSION TYPE HEADACHE 340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE 341.22 IDIOPATHIC TRANSVERSE MYELITIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED 342.10 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE

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344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5 UNSPECIFIED MONOPLEGIA MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS - MIGRAINE WITH AURA, 346.01 - 346.03 WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.11 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.13 WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.21 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.23 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.31 WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.33 WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.41 WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.43 WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.51 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.53 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.61 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.63 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.81 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS 346.83 OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO Page 61 of 107

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STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.90 MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.91 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.92 MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 350.9 TRIGEMINAL NERVE DISORDER UNSPECIFIED 351.8 OTHER FACIAL NERVE DISORDERS 351.9 FACIAL NERVE DISORDER UNSPECIFIED 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA

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378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME 378.62 MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE

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438.53 OTHER PARALYTIC SYNDROME BILATERAL 478.31 PARTIAL UNILATERAL PARALYSIS OF VOCAL CORDS 478.33 PARTIAL BILATERAL PARALYSIS OF VOCAL CORDS 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE 784.42 DYSPHONIA 788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE)

Jurisdiction(s): 9 (N) NCD/LCD Document (s): L29088; L29103 ICD-9 Codes Diagnosis 333.83 SPASMODIC TORTICOLLIS 723.5 TORTICOLLIS UNSPECIFIED

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NERVOUS SYSTEM UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.10 - 342.12 - SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 343.0 - 343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 - 344.5 QUADRIPLEGIA UNSPECIFIED - UNSPECIFIED MONOPLEGIA MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.01 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITH AURA, WITHOUT MENTION OF INTRACTABLE 346.02 MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.03 WITH STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.11 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.13 STATED, WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.21 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.23 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.31 WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.33 WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.41 WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.43 WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.51 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.53 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.61 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.63 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.81 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS Page 65 of 107

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OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.83 STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.91 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 350.9 TRIGEMINAL NERVE DISORDER UNSPECIFIED OTHER FACIAL NERVE DISORDERS - FACIAL NERVE DISORDER 351.8 - 351.9 UNSPECIFIED 374.03 SPASTIC ENTROPION ESOTROPIA UNSPECIFIED - UNSPECIFIED DISORDER OF EYE 378.00 - 378.9 MOVEMENTS MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE - 438.31 - 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 478.31 PARTIAL UNILATERAL PARALYSIS OF VOCAL CORDS 478.33 PARTIAL BILATERAL PARALYSIS OF VOCAL CORDS 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE 729.82 CRAMP OF LIMB 784.42 DYSPHONIA

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341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE 341.22 IDIOPATHIC TRANSVERSE MYELITIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM 341.9 UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED 342.10 SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.01 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.11 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.70 INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS

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CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.90 MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.91 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.92 MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 351.8 OTHER FACIAL NERVE DISORDERS 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING

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378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL 378.62 DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE

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438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.52 LOW BLADDER COMPLIANCE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE

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MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.13 WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.70 INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS 350.8 OTHER SPECIFIED TRIGEMINAL NERVE DISORDERS 351.8 OTHER FACIAL NERVE DISORDERS 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION 375.21 EPIPHORA DUE TO EXCESS LACRIMATION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA

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378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME 378.62 MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 478.29 OTHER DISEASES OF PHARYNX OR NASOPHARYNX 478.75 LARYNGEAL SPASM 478.79 OTHER DISEASES OF LARYNX 527.7 DISTURBANCE OF SALIVARY SECRETION 529.8 OTHER SPECIFIED CONDITIONS OF THE TONGUE 530.0 ACHALASIA AND CARDIOSPASM 530.89 OTHER DISEASES OF ESOPHAGUS 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.52 LOW BLADDER COMPLIANCE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 596.59 OTHER FUNCTIONAL DISORDER OF BLADDER 596.89 OTHER SPECIFIED DISORDERS OF BLADDER 705.21 PRIMARY FOCAL HYPERHIDROSIS 705.22 SECONDARY FOCAL HYPERHIDROSIS 728.85* SPASM OF MUSCLE 784.49 OTHER VOICE AND RESONANCE DISORDERS 788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE)

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788.39 OTHER URINARY INCONTINENCE Secondary Codes Must be used along with ICD-9 code 728.85 340* MULTIPLE SCLEROSIS 342.11* SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12* SIDE 343.8* OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9* INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00* QUADRIPLEGIA UNSPECIFIED 344.01* QUADRIPLEGIA C1-C4 COMPLETE 344.02* QUADRIPLEGIA C1-C4 INCOMPLETE 344.03* QUADRIPLEGIA C5-C7 COMPLETE 344.04* QUADRIPLEGIA C5-C7 INCOMPLETE 344.09* OTHER QUADRIPLEGIA 344.1* PARAPLEGIA 344.2* DIPLEGIA OF UPPER LIMBS 344.30* MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31* MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32* MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40* MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41* MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42* MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5* UNSPECIFIED MONOPLEGIA 344.60* CAUDA EQUINA SYNDROME WITHOUT NEUROGENIC BLADDER 430* SUBARACHNOID HEMORRHAGE 431* INTRACEREBRAL HEMORRHAGE 432.0* NONTRAUMATIC EXTRADURAL HEMORRHAGE 432.1* SUBDURAL HEMORRHAGE OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL 433.01* INFARCTION OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL 433.11* INFARCTION OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL 433.21* INFARCTION OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL 433.31* ARTERIES WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY 433.81* WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY 433.91* WITH CEREBRAL INFARCTION 434.01* CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION 434.11* CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL 434.91* INFARCTION 438.21* HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22* HEMIPLEGIA AFFECTING NONDOMINANT SIDE

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438.31* MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32* MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.41* MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 438.42* MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.51* OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52* OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53* OTHER PARALYTIC SYNDROME BILATERAL 952.00* C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.01* C1-C4 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.02* C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME 952.03* C1-C4 LEVEL WITH CENTRAL CORD SYNDROME 952.04* C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.05* C5-C7 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.06* C5-C7 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.07* C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME 952.08* C5-C7 LEVEL WITH CENTRAL CORD SYNDROME 952.09* C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.10* T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.11* T1-T6 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.12* T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME 952.13* T1-T6 LEVEL WITH CENTRAL CORD SYNDROME 952.14* T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.15* T7-T12 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.16* T7-T12 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.17* T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME 952.18* T7-T12 LEVEL WITH CENTRAL CORD SYNDROME 952.19* T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 997.01* CENTRAL NERVOUS SYSTEM COMPLICATION 997.02* IATROGENIC CEREBROVASCULAR INFARCTION OR HEMORRHAGE

Botulinum Toxins Medical Necessity Criteria Last Review Date: 03/25/2014 Number: IC-0022

343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS 346.70 - 346.73 - CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS 350.8 OTHER SPECIFIED TRIGEMINAL NERVE DISORDERS 351.8 OTHER FACIAL NERVE DISORDERS 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA

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378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME 378.62 MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 478.29 OTHER DISEASES OF PHARYNX OR NASOPHARYNX 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.52 LOW BLADDER COMPLIANCE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 705.22 SECONDARY FOCAL HYPERHIDROSIS

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728.85* SPASM OF MUSCLE 784.49 OTHER VOICE AND RESONANCE DISORDERS 788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE) 788.41 URINARY FREQUENCY Secondary Codes Must be used along with ICD-9 code 728.85 340* MULTIPLE SCLEROSIS 342.11* SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12* SIDE 344.1* PARAPLEGIA 344.2* DIPLEGIA OF UPPER LIMBS 344.5* UNSPECIFIED MONOPLEGIA 430* SUBARACHNOID HEMORRHAGE 431* INTRACEREBRAL HEMORRHAGE 432.0* NONTRAUMATIC EXTRADURAL HEMORRHAGE 432.1* SUBDURAL HEMORRHAGE OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL 433.01* INFARCTION OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL 433.11* INFARCTION OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL 433.21* INFARCTION OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL 433.31* ARTERIES WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY 433.81* WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY 433.91* WITH CEREBRAL INFARCTION 434.01* CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION 434.11* CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL 434.91* INFARCTION 438.21* HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22* HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.31* MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32* MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.41* MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 438.42* MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.51* OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE

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438.52* OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53* OTHER PARALYTIC SYNDROME BILATERAL 952.00* C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.01* C1-C4 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.02* C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME 952.03* C1-C4 LEVEL WITH CENTRAL CORD SYNDROME 952.04* C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.05* C5-C7 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.06* C5-C7 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.07* C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME 952.08* C5-C7 LEVEL WITH CENTRAL CORD SYNDROME 952.09* C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.10* T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.11* T1-T6 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.12* T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME 952.13* T1-T6 LEVEL WITH CENTRAL CORD SYNDROME 952.14* T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.15* T7-T12 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.16* T7-T12 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.17* T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME 952.18* T7-T12 LEVEL WITH CENTRAL CORD SYNDROME 952.19* T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 997.01* CENTRAL NERVOUS SYSTEM COMPLICATION 997.02* IATROGENIC CEREBROVASCULAR INFARCTION OR HEMORRHAGE

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334.1 HEREDITARY SPASTIC PARAPLEGIA 340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED 342.10 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5 UNSPECIFIED MONOPLEGIA 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.70 INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS

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CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS 351.8 OTHER FACIAL NERVE DISORDERS 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION ESOTROPIA UNSPECIFIED - ALTERNATING ESOTROPIA WITH OTHER 378.00 - 378.08 NONCOMITANCIES EXOTROPIA UNSPECIFIED - ALTERNATING EXOTROPIA WITH OTHER 378.10 - 378.18 NONCOMITANCIES INTERMITTENT HETEROTROPIA UNSPECIFIED - INTERMITTENT 378.20 - 378.24 EXOTROPIA ALTERNATING HETEROTROPIA UNSPECIFIED - ACCOMMODATIVE COMPONENT IN 378.30 - 378.35 ESOTROPIA 378.40 - 378.45 HETEROPHORIA UNSPECIFIED - ALTERNATING HYPERPHORIA 378.50 - 378.56 PARALYTIC STRABISMUS UNSPECIFIED - TOTAL OPHTHALMOPLEGIA MECHANICAL STRABISMUS UNSPECIFIED - LIMITED DUCTION 378.60 - 378.63 ASSOCIATED WITH OTHER CONDITIONS DUANE'S SYNDROME - STRABISMUS IN OTHER NEUROMUSCULAR 378.71 - 378.73 DISORDERS PALSY OF CONJUGATE GAZE - OTHER DISSOCIATED DEVIATION OF EYE 378.81 - 378.87 MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.0 COGNITIVE DEFICITS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.41 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL UNSPECIFIED PARALYSIS OF VOCAL CORDS - COMPLETE BILATERAL 478.30 - 478.34 PARALYSIS OF VOCAL CORDS

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478.75 LARYNGEAL SPASM 527.2 SIALOADENITIS 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 596.59 OTHER FUNCTIONAL DISORDER OF BLADDER

705.21 PRIMARY FOCAL HYPERHIDROSIS

Xeomin (J0588)

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MYELITIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - 342.10 – 342.12 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 343.0 - 343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 – 344.5 QUADRIPLEGIA UNSPECIFIED - UNSPECIFIED MONOPLEGIA HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING 438.20 – 438.22 NONDOMINANT SIDE MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE - 438.30 – 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - 438.40 – 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 527.7 DISTURBANCE OF SALIVARY SECRETION 705.21 PRIMARY FOCAL HYPERHIDROSIS 705.22 SECONDARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE CONGENITAL MUSCULOSKELETAL DEFORMITIES OF 754.1 STERNOCLEIDOMASTOID MUSCLE 780.8 GENERALIZED HYPERHIDROSIS

Jurisdiction(s): 15 NCD/LCD Document (s): L31855 ICD-9 Codes Diagnosis 307.81 TENSION HEADACHE 333.6 GENETIC TORSION DYSTONIA 333.71 ATHETOID CEREBRAL PALSY 333.72 ACUTE DYSTONIA DUE TO DRUGS 333.79 OTHER ACQUIRED TORSION DYSTONIA 333.81 BLEPHAROSPASM 333.82 OROFACIAL DYSKINESIA 333.83 SPASMODIC TORTICOLLIS 333.84 ORGANIC WRITERS' CRAMP 333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 339.02 CHRONIC CLUSTER HEADACHE 339.12 CHRONIC TENSION TYPE HEADACHE 340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA

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341.1 SCHILDER'S DISEASE 341.22 IDIOPATHIC TRANSVERSE MYELITIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED 342.10 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5 UNSPECIFIED MONOPLEGIA MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS - MIGRAINE WITH AURA, 346.01 - 346.03 WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.11 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.13 WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.21 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS

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MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.23 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.31 WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.33 WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.41 WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.43 WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.51 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.53 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.61 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.63 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.81 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.83 STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.90 MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.91 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.92 MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 350.9 TRIGEMINAL NERVE DISORDER UNSPECIFIED 351.8 OTHER FACIAL NERVE DISORDERS 351.9 FACIAL NERVE DISORDER UNSPECIFIED 374.03 SPASTIC ENTROPION Page 84 of 107

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374.13 SPASTIC ECTROPION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY

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378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME 378.62 MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL 478.31 PARTIAL UNILATERAL PARALYSIS OF VOCAL CORDS 478.33 PARTIAL BILATERAL PARALYSIS OF VOCAL CORDS 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE

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784.42 DYSPHONIA 788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE)

Jurisdiction(s): 9 (N) NCD/LCD Document (s): L29088; L29103 ICD-9 Codes Diagnosis 333.81 BLEPHAROSPASM 333.83 SPASMODIC TORTICOLLIS 723.5 TORTICOLLIS UNSPECIFIED

Jurisdiction(s): 11 (M) NCD/LCD Document (s): L31701 ICD-9 Codes Diagnosis 307.81 TENSION HEADACHE 333.6 GENETIC TORSION DYSTONIA 333.71 ATHETOID CEREBRAL PALSY 333.72 ACUTE DYSTONIA DUE TO DRUGS 333.79 OTHER ACQUIRED TORSION DYSTONIA 333.81 BLEPHAROSPASM 333.82 OROFACIAL DYSKINESIA 333.83 SPASMODIC TORTICOLLIS 333.84 ORGANIC WRITERS' CRAMP 333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 339.02 CHRONIC CLUSTER HEADACHE 339.12 CHRONIC TENSION TYPE HEADACHE 340 MULTIPLE SCLEROSIS NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL 341.0 - 341.9 NERVOUS SYSTEM UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE 342.10 - 342.12 - SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE 343.0 - 343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 - 344.5 QUADRIPLEGIA UNSPECIFIED - UNSPECIFIED MONOPLEGIA MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.01 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITH AURA, WITHOUT MENTION OF INTRACTABLE 346.02 MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.03 WITH STATUS MIGRAINOSUS

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MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.11 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.13 STATED, WITH STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.21 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS VARIANTS OF MIGRAINE, NOT ELSEWHERE CLASSIFIED, WITH 346.23 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.31 WITHOUT MENTION OF STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.33 WITH STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.41 WITHOUT MENTION OF STATUS MIGRAINOSUS MENSTRUAL MIGRAINE, WITH INTRACTABLE MIGRAINE, SO STATED, 346.43 WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.51 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, WITH 346.53 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.61 INTRACTABLE MIGRAINE, SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, WITH 346.63 INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.81 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS OTHER FORMS OF MIGRAINE, WITH INTRACTABLE MIGRAINE, SO 346.83 STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.91 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 350.9 TRIGEMINAL NERVE DISORDER UNSPECIFIED OTHER FACIAL NERVE DISORDERS - FACIAL NERVE DISORDER 351.8 - 351.9 UNSPECIFIED 374.03 SPASTIC ENTROPION ESOTROPIA UNSPECIFIED - UNSPECIFIED DISORDER OF EYE 378.00 - 378.9 MOVEMENTS Page 88 of 107

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MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE - 438.31 - 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 478.31 PARTIAL UNILATERAL PARALYSIS OF VOCAL CORDS 478.33 PARTIAL BILATERAL PARALYSIS OF VOCAL CORDS 478.75 LARYNGEAL SPASM 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE 729.82 CRAMP OF LIMB 784.42 DYSPHONIA

Jurisdiction(s): 6,K NCD/LCD Document (s): L26841 ICD-9 Codes Diagnosis 333.6 GENETIC TORSION DYSTONIA 333.71 ATHETOID CEREBRAL PALSY 333.79 OTHER ACQUIRED TORSION DYSTONIA 333.81 BLEPHAROSPASM 333.82 OROFACIAL DYSKINESIA 333.83 SPASMODIC TORTICOLLIS 333.84 ORGANIC WRITERS' CRAMP 333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 339.12 CHRONIC TENSION TYPE HEADACHE 340 MULTIPLE SCLEROSIS 341.0 NEUROMYELITIS OPTICA 341.1 SCHILDER'S DISEASE 341.22 IDIOPATHIC TRANSVERSE MYELITIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM 341.9 UNSPECIFIED SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED 342.10 SIDE 342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12 SIDE 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA Page 89 of 107

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343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.01 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO 346.11 STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.70 INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.90 MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.91 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITHOUT MENTION OF INTRACTABLE 346.92 MIGRAINE WITH STATUS MIGRAINOSUS MIGRAINE, UNSPECIFIED, WITH INTRACTABLE MIGRAINE, SO STATED, 346.93 WITH STATUS MIGRAINOSUS 351.8 OTHER FACIAL NERVE DISORDERS Page 90 of 107

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374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN 378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL

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378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL 378.62 DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.52 LOW BLADDER COMPLIANCE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 723.5 TORTICOLLIS UNSPECIFIED

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728.85 SPASM OF MUSCLE

Jurisdiction(s): F NCD/LCD Document (s): L24280 ICD-9 Codes Diagnosis 333.2 MYOCLONUS 333.6 GENETIC TORSION DYSTONIA 333.79 OTHER ACQUIRED TORSION DYSTONIA 333.81 BLEPHAROSPASM 333.82 OROFACIAL DYSKINESIA 333.83 SPASMODIC TORTICOLLIS 333.84 ORGANIC WRITERS' CRAMP 333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 341.1 SCHILDER'S DISEASE 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.01 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITH AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.03 WITH STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.11 WITHOUT MENTION OF STATUS MIGRAINOSUS MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, 346.13 WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.70 INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS 350.8 OTHER SPECIFIED TRIGEMINAL NERVE DISORDERS 351.8 OTHER FACIAL NERVE DISORDERS 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION 375.21 EPIPHORA DUE TO EXCESS LACRIMATION 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN Page 93 of 107

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378.03 MONOCULAR ESOTROPIA WITH V PATTERN 378.04 MONOCULAR ESOTROPIA WITH OTHER NONCOMITANCIES 378.05 ALTERNATING ESOTROPIA 378.06 ALTERNATING ESOTROPIA WITH A PATTERN 378.07 ALTERNATING ESOTROPIA WITH V PATTERN 378.08 ALTERNATING ESOTROPIA WITH OTHER NONCOMITANCIES 378.10 EXOTROPIA UNSPECIFIED 378.11 MONOCULAR EXOTROPIA 378.12 MONOCULAR EXOTROPIA WITH A PATTERN 378.13 MONOCULAR EXOTROPIA WITH V PATTERN 378.14 MONOCULAR EXOTROPIA WITH OTHER NONCOMITANCIES 378.15 ALTERNATING EXOTROPIA 378.16 ALTERNATING EXOTROPIA WITH A PATTERN 378.17 ALTERNATING EXOTROPIA WITH V PATTERN 378.18 ALTERNATING EXOTROPIA WITH OTHER NONCOMITANCIES 378.20 INTERMITTENT HETEROTROPIA UNSPECIFIED 378.21 INTERMITTENT ESOTROPIA MONOCULAR 378.22 INTERMITTENT ESOTROPIA ALTERNATING 378.23 INTERMITTENT EXOTROPIA MONOCULAR 378.24 INTERMITTENT EXOTROPIA ALTERNATING 378.30 HETEROTROPIA UNSPECIFIED 378.31 HYPERTROPIA 378.32 HYPOTROPIA 378.33 CYCLOTROPIA 378.34 MONOFIXATION SYNDROME 378.35 ACCOMMODATIVE COMPONENT IN ESOTROPIA 378.40 HETEROPHORIA UNSPECIFIED 378.41 ESOPHORIA 378.42 EXOPHORIA 378.43 VERTICAL HETEROPHORIA 378.44 CYCLOPHORIA 378.45 ALTERNATING HYPERPHORIA 378.50 PARALYTIC STRABISMUS UNSPECIFIED 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL 378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 378.55 EXTERNAL OPHTHALMOPLEGIA 378.56 TOTAL OPHTHALMOPLEGIA 378.60 MECHANICAL STRABISMUS UNSPECIFIED 378.61 BROWN'S (TENDON) SHEATH SYNDROME 378.62 MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.71 DUANE'S SYNDROME 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS

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378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 478.29 OTHER DISEASES OF PHARYNX OR NASOPHARYNX 478.75 LARYNGEAL SPASM 478.79 OTHER DISEASES OF LARYNX 527.7 DISTURBANCE OF SALIVARY SECRETION 529.8 OTHER SPECIFIED CONDITIONS OF THE TONGUE 530.0 ACHALASIA AND CARDIOSPASM 530.89 OTHER DISEASES OF ESOPHAGUS 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.52 LOW BLADDER COMPLIANCE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 596.59 OTHER FUNCTIONAL DISORDER OF BLADDER 596.89 OTHER SPECIFIED DISORDERS OF BLADDER 705.21 PRIMARY FOCAL HYPERHIDROSIS 705.22 SECONDARY FOCAL HYPERHIDROSIS 728.85* SPASM OF MUSCLE 784.49 OTHER VOICE AND RESONANCE DISORDERS 788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE) 788.39 OTHER URINARY INCONTINENCE Secondary Codes Must be used along with ICD-9 code 728.85 340* MULTIPLE SCLEROSIS 342.11* SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12* SIDE 343.8* OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9* INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00* QUADRIPLEGIA UNSPECIFIED 344.01* QUADRIPLEGIA C1-C4 COMPLETE 344.02* QUADRIPLEGIA C1-C4 INCOMPLETE 344.03* QUADRIPLEGIA C5-C7 COMPLETE 344.04* QUADRIPLEGIA C5-C7 INCOMPLETE 344.09* OTHER QUADRIPLEGIA 344.1* PARAPLEGIA 344.2* DIPLEGIA OF UPPER LIMBS 344.30* MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31* MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE

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344.32* MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40* MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41* MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42* MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5* UNSPECIFIED MONOPLEGIA 344.60* CAUDA EQUINA SYNDROME WITHOUT NEUROGENIC BLADDER 430* SUBARACHNOID HEMORRHAGE 431* INTRACEREBRAL HEMORRHAGE 432.0* NONTRAUMATIC EXTRADURAL HEMORRHAGE 432.1* SUBDURAL HEMORRHAGE OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL 433.01* INFARCTION OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL 433.11* INFARCTION OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL 433.21* INFARCTION OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL 433.31* ARTERIES WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY 433.81* WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY 433.91* WITH CEREBRAL INFARCTION 434.01* CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION 434.11* CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL 434.91* INFARCTION 438.21* HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22* HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.31* MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32* MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.41* MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 438.42* MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.51* OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52* OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53* OTHER PARALYTIC SYNDROME BILATERAL 952.00* C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.01* C1-C4 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.02* C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME 952.03* C1-C4 LEVEL WITH CENTRAL CORD SYNDROME 952.04* C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.05* C5-C7 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.06* C5-C7 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.07* C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME 952.08* C5-C7 LEVEL WITH CENTRAL CORD SYNDROME 952.09* C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.10* T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED

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952.11* T1-T6 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.12* T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME 952.13* T1-T6 LEVEL WITH CENTRAL CORD SYNDROME 952.14* T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.15* T7-T12 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.16* T7-T12 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.17* T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME 952.18* T7-T12 LEVEL WITH CENTRAL CORD SYNDROME 952.19* T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 997.01* CENTRAL NERVOUS SYSTEM COMPLICATION 997.02* IATROGENIC CEREBROVASCULAR INFARCTION OR HEMORRHAGE

Jurisdiction(s): 1 (E) NCD/LCD Document (s): L33513 ICD-9 Codes Diagnosis 333.6 GENETIC TORSION DYSTONIA 333.79 OTHER ACQUIRED TORSION DYSTONIA 333.81 BLEPHAROSPASM 333.82 OROFACIAL DYSKINESIA 333.83 SPASMODIC TORTICOLLIS 333.84 ORGANIC WRITERS' CRAMP 333.89 OTHER FRAGMENTS OF TORSION DYSTONIA 334.1 HEREDITARY SPASTIC PARAPLEGIA 341.1 SCHILDER'S DISEASE 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 341.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED 343.0 CONGENITAL DIPLEGIA 343.1 CONGENITAL HEMIPLEGIA 343.2 CONGENITAL QUADRIPLEGIA 343.3 CONGENITAL MONOPLEGIA 343.4 INFANTILE HEMIPLEGIA 343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS 346.70 - 346.73 - CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, SO STATED, WITH STATUS MIGRAINOSUS 350.8 OTHER SPECIFIED TRIGEMINAL NERVE DISORDERS 351.8 OTHER FACIAL NERVE DISORDERS 378.00 ESOTROPIA UNSPECIFIED 378.01 MONOCULAR ESOTROPIA 378.02 MONOCULAR ESOTROPIA WITH A PATTERN Page 97 of 107

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378.61 BROWN'S (TENDON) SHEATH SYNDROME 378.62 MECHANICAL STRABISMUS FROM OTHER MUSCULOFASCIAL DISORDERS 378.63 LIMITED DUCTION ASSOCIATED WITH OTHER CONDITIONS 378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 378.81 PALSY OF CONJUGATE GAZE 378.82 SPASM OF CONJUGATE GAZE 378.83 CONVERGENCE INSUFFICIENCY OR PALSY 378.84 CONVERGENCE EXCESS OR SPASM 378.85 ANOMALIES OF DIVERGENCE 378.86 INTERNUCLEAR OPHTHALMOPLEGIA 378.87 OTHER DISSOCIATED DEVIATION OF EYE MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 478.29 OTHER DISEASES OF PHARYNX OR NASOPHARYNX 478.75 LARYNGEAL SPASM 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.52 LOW BLADDER COMPLIANCE 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 705.21 PRIMARY FOCAL HYPERHIDROSIS 705.22 SECONDARY FOCAL HYPERHIDROSIS 728.85* SPASM OF MUSCLE 784.49 OTHER VOICE AND RESONANCE DISORDERS 788.31 URGE INCONTINENCE 788.33 MIXED INCONTINENCE (MALE) (FEMALE) 788.41 URINARY FREQUENCY Secondary Codes Must be used along with ICD-9 code 728.85 340* MULTIPLE SCLEROSIS 342.11* SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT 342.12* SIDE 344.1* PARAPLEGIA 344.2* DIPLEGIA OF UPPER LIMBS 344.5* UNSPECIFIED MONOPLEGIA 430* SUBARACHNOID HEMORRHAGE 431* INTRACEREBRAL HEMORRHAGE 432.0* NONTRAUMATIC EXTRADURAL HEMORRHAGE

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432.1* SUBDURAL HEMORRHAGE OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL 433.01* INFARCTION OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL 433.11* INFARCTION OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL 433.21* INFARCTION OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL 433.31* ARTERIES WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY 433.81* WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY 433.91* WITH CEREBRAL INFARCTION 434.01* CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION 434.11* CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL 434.91* INFARCTION 438.21* HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22* HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.31* MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32* MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.41* MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 438.42* MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.51* OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52* OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53* OTHER PARALYTIC SYNDROME BILATERAL 952.00* C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.01* C1-C4 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.02* C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME 952.03* C1-C4 LEVEL WITH CENTRAL CORD SYNDROME 952.04* C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.05* C5-C7 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.06* C5-C7 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.07* C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME 952.08* C5-C7 LEVEL WITH CENTRAL CORD SYNDROME 952.09* C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.10* T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.11* T1-T6 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.12* T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME 952.13* T1-T6 LEVEL WITH CENTRAL CORD SYNDROME

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952.14* T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.15* T7-T12 LEVEL SPINAL CORD INJURY UNSPECIFIED 952.16* T7-T12 LEVEL WITH COMPLETE LESION OF SPINAL CORD 952.17* T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME 952.18* T7-T12 LEVEL WITH CENTRAL CORD SYNDROME 952.19* T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 997.01* CENTRAL NERVOUS SYSTEM COMPLICATION 997.02* IATROGENIC CEREBROVASCULAR INFARCTION OR HEMORRHAGE

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343.8 OTHER SPECIFIED INFANTILE CEREBRAL PALSY 343.9 INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00 QUADRIPLEGIA UNSPECIFIED 344.01 QUADRIPLEGIA C1-C4 COMPLETE 344.02 QUADRIPLEGIA C1-C4 INCOMPLETE 344.03 QUADRIPLEGIA C5-C7 COMPLETE 344.04 QUADRIPLEGIA C5-C7 INCOMPLETE 344.09 OTHER QUADRIPLEGIA 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.30 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE 344.31 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 344.40 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 344.41 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE 344.5 UNSPECIFIED MONOPLEGIA 344.61 CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.70 INTRACTABLE MIGRAINE WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.71 SO STATED, WITHOUT MENTION OF STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITHOUT MENTION OF 346.72 INTRACTABLE MIGRAINE WITH STATUS MIGRAINOSUS CHRONIC MIGRAINE WITHOUT AURA, WITH INTRACTABLE MIGRAINE, 346.73 SO STATED, WITH STATUS MIGRAINOSUS 351.8 OTHER FACIAL NERVE DISORDERS 374.03 SPASTIC ENTROPION 374.13 SPASTIC ECTROPION ESOTROPIA UNSPECIFIED - ALTERNATING ESOTROPIA WITH OTHER 378.00 - 378.08 NONCOMITANCIES EXOTROPIA UNSPECIFIED - ALTERNATING EXOTROPIA WITH OTHER 378.10 - 378.18 NONCOMITANCIES INTERMITTENT HETEROTROPIA UNSPECIFIED - INTERMITTENT 378.20 - 378.24 EXOTROPIA ALTERNATING HETEROTROPIA UNSPECIFIED - ACCOMMODATIVE COMPONENT IN 378.30 - 378.35 ESOTROPIA 378.40 - 378.45 HETEROPHORIA UNSPECIFIED - ALTERNATING HYPERPHORIA

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378.50 - 378.56 PARALYTIC STRABISMUS UNSPECIFIED - TOTAL OPHTHALMOPLEGIA MECHANICAL STRABISMUS UNSPECIFIED - LIMITED DUCTION 378.60 - 378.63 ASSOCIATED WITH OTHER CONDITIONS DUANE'S SYNDROME - STRABISMUS IN OTHER NEUROMUSCULAR 378.71 - 378.73 DISORDERS PALSY OF CONJUGATE GAZE - OTHER DISSOCIATED DEVIATION OF EYE 378.81 - 378.87 MOVEMENTS 378.9 UNSPECIFIED DISORDER OF EYE MOVEMENTS 438.0 COGNITIVE DEFICITS 438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE 438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE 438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.30 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE 438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE 438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE 438.41 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.50 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE 438.51 OTHER PARALYTIC SYNDROME AFFECTING DOMINANT SIDE 438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 438.53 OTHER PARALYTIC SYNDROME BILATERAL UNSPECIFIED PARALYSIS OF VOCAL CORDS - COMPLETE BILATERAL 478.30 - 478.34 PARALYSIS OF VOCAL CORDS 478.75 LARYNGEAL SPASM 527.2 SIALOADENITIS 527.7 DISTURBANCE OF SALIVARY SECRETION 530.0 ACHALASIA AND CARDIOSPASM 565.0 ANAL FISSURE 596.51 HYPERTONICITY OF BLADDER 596.54 NEUROGENIC BLADDER NOS 596.55 DETRUSOR SPHINCTER DYSSYNERGIA 596.59 OTHER FUNCTIONAL DISORDER OF BLADDER

705.21 PRIMARY FOCAL HYPERHIDROSIS

723.5 TORTICOLLIS UNSPECIFIED 728.85 SPASM OF MUSCLE 729.89 OTHER MUSCULOSKELETAL SYMPTOMS REFERABLE TO LIMBS 754.1 CONGENITAL MUSCULOSKELETAL DEFORMITIES OF

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STERNOCLEIDOMASTOID MUSCLE 781.0 ABNORMAL INVOLUNTARY MOVEMENTS VOICE AND RESONANCE DISORDER, UNSPECIFIED - OTHER VOICE AND 784.40 - 784.49 RESONANCE DISORDERS 784.51 DYSARTHRIA 784.52 FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE 784.59 OTHER SPEECH DISTURBANCE 788.31 URGE INCONTINENCE 788.41 URINARY FREQUENCY

VIII. Criteria Exclusions: o Treatment for diagnoses not FDA approved o All indications not described in Section III Review criteria are not covered and may be considered experimental or investigational.

IX. Black Box Warnings/Contraindications: Black Box Warnings The effects of all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults, particularly in those patients who have an underlying condition that would predispose them to these symptoms.

Botox Contraindications o Hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation. o Infection at the proposed injection site. o Intradetrusor Injections: Acute Urinary Tract Infection and/or Acute Urinary Retention.

Dysport Contraindications o Hypersensitivity to any botulinum toxin product or excipients. o Allergy to cow’s milk protein. o Infection at the proposed injection site

Myobloc Contraindications o Hypersensitivity to any botulinum toxin preparation or to any of the components of the formulation. o Infection at the proposed injection site.

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Botulinum Toxins Medical Necessity Criteria Last Review Date: 03/25/2014 Number: IC-0022

Xeomin Contraindications o Known hypersensitivity to the active substance botulinum neruotoxin type A or to any of the excipients. o Infection at the proposed injection site.

X. References: 1. Botox [package insert]. Irvine, CA; Allergan, Inc; September 2013. Accessed March 2014. 2. Dysport [package insert]. Wrexham, UK; Ipsen Biopharm Ltd; March 2012. Accessed March 2014. 3. Myobloc [package insert]. South San Francisco, CA; Solstice Neurosciences, Inc.; May 2010. Accessed March 2014. 4. Xeomin [package insert]. Dessau-Rosslau, Germany; Merz Group Services GmbH; July 2011. Accessed March 2014. 5. Ondo WG, Hunter C, Moore W. A double-blind placebo-controlled trial of botulinum toxin B for sialorrhea in Parkinson's disease. Neurology. 2004;62:37-40. 6. Racette BA, Good L, Sagitto S, Perlmutter JS. Botulinum toxin B reduces sialorrhea in parkinsonism. Mov Disord. 2003;18:1059-1061. 7. Simpson DM, Blitzer A, Brashear A, Comella C, Dubinsky R, Hallett M, Jankovic J, Karp B, Ludlow CL, Miyasaki JM, Naumann M, So Y, Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: Botulinum neurotoxin for the treatment of movement disorders (an evidence- based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2008 May 6;70(19):1699-706. 8. Naumann M, So Y, Argoff CE, Childers MK, Dykstra DD, Gronseth GS, Jabbari B, Kaufmann HC, Schurch B, Silberstein SD, Simpson DM, Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: Botulinum neurotoxin in the treatment of autonomic disorders and pain (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2008 May 6;70(19):1707-14. 9. Quality Standards Subcommittee of the American Academy of Neurology, Practice Committee of the Child Neurology Society, Delgado MR, Hirtz D, Aisen M, Ashwal S, Fehlings DL, McLaughlin J, Morrison LA, Shrader MW, Tilton A, Vargus-Adams J. Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review). Report of the Quality Standards Subcommittee of the AAN and Practice Committee of the Child Neurology Society. Neurology 2010 Jan 26;74(4):336-43. 10. Egan JV, Baron TH, Adler DG, Davila R, Faigel DO, Gan SL, Hirota WK, Leighton JA, Lichtenstein D, Qureshi WA, Rajan E, Shen B, Zuckerman MJ, Vanguilder T, Fanelli RD, Standards of Practice Committee. Esophageal dilation. Gastrointest Endosc 2006 May;63(6):755-60. 11. Koman LA, Brashear A, Rosenfeld, et al. Botulinum toxin type A neuromuscular blockade in the treatment of equinus foot deformity in cerebral palsy: A multicenter, Open-label Clinical trial. Pediatrics 2001;108:1062- 1071. 12. Oman LA, Mooney JF III, Smith BP, et al. Botulinum toxin type A neuromuscular blockade in the treatment of lower extremity spasticity in cerebral palsy: A randomized, double-blind, placebo controlled trial. J Pediatr Orthop 2000;20:108-115. 13. Cahaba Government Benefit Administrators, LLC. Local Coverage Determination (LCD): Botulinum Toxins (L30025). Centers for Medicare & Medicaid Services, Inc. Updated on 02/22/2013 with effective date 03/01/2013. Accessed February 2014. 14. CGS, Administrators, LLC. Local Coverage Determination (LCD): Botulinum Toxins (L31855). Centers for Medicare & Medicaid Services, Inc. Updated on 1/2/2014 with effective date 01/01/2014. Accessed February 2014.

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Botulinum Toxins Medical Necessity Criteria Last Review Date: 03/25/2014 Number: IC-0022

15. First Coast Service Options, Inc. Local Coverage Determination (LCD): Botulinum Toxins (L29088; L29103). Centers for Medicare & Medicaid Services, Inc. Updated on 05/08/2013 with effective date 01/18/2013. Accessed February 2014. 16. National Government Services, Inc. Local Coverage Determination (LCD): Botulinum Toxins (L26841). Centers for Medicare & Medicaid Services, Inc. Updated on 1/10/2014 with effective date 1/16/2014. Accessed February 2014. 17. Noridian Administrative Services, LLC. Local Coverage Determination (LCD): Botulinum Toxin Types A and B (L24280). Centers for Medicare & Medicaid Services, Inc. Updated on 1/2/2014 with effective date 1/1/2014. Accessed February 2014. 18. Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD): Botulinum Toxin Types A and B (L33513). Centers for Medicare & Medicaid Services, Inc. Updated on 1/2/2014 with effective date 1/1/2014. Accessed February 2014. 19. Palmetto GBA. Local Coverage Determination (LCD): Chemodenervation (L31701). Centers for Medicare & Medicaid Services, Inc. Updated on 01/17/2014 with effective date 01/24/2014. Accessed February 2014. 20. Wisconsin Physicians Service Insurance Corporation. Local Coverage Determination (LCD): Botulinum Toxin Type A & Type B (L28555). Centers for Medicare & Medicaid Services, Inc. Updated on 1/3/2014 with effective date 1/1/2014. Accessed February 2014. 21. Vaezi MF, Pandolfino JE, Vela MF. ACG Clinical Guideline: Diagnosis and Management of Achalasia. Am J Gastroenterol 2013;108:1238-49. 22. Lipp A, Trottenberg T, Schink T, et al. A randomized trial of botulinum toxin A for treatment of drooling Neurology. 2003;61:1279-1281. 23. Simpson DM, Gracies JM, Graham HK, Miyasaki JM, Naumann M, Russman B, Simpson LL, So Y; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: Botulinum neurotoxin for the treatment of spasticity (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2008 May 6;70(19):1691-8 24. Perry WB, Dykes SL, Buie WD, Rafferty JF, Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of anal fissures (3rd revision). Dis Colon Rectum. 2010 Aug;53(8):1110-5. 25. Schwartz S, Cohen S, Dailey S, Rosenfeld R, Deutsch E, Gillespie B, Granieri E, Hapner E, Kimball E, Krouse H, McMurray S, Medina S, O'Brien K, Ouellette D, Messinger-Rapport B, Stachler R, Strode S, Thompson D, Stemple J, Willging P, Cowley T, McCoy, Bernad P, Patel M. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009 Sep;141(3S2):S1-S31. 26. Cillino S(1), Raimondi G, Guépratte N, Damiani S, Cillino M, Di Pace F, Casuccio A. Long-term efficacy of botulinum toxin A for treatment of blepharospasm, hemifacial spasm, and spastic entropion: a multicentre study using two drug-dose escalation indexes. Eye (Lond). 2010 Apr;24(4):600-7. doi: 10.1038/eye.2009.192. 27. Defazio G(1), Abbruzzese G, Girlanda P, Vacca L, Currà A, De Salvia R, Marchese R, Raineri R, Roselli F, Livrea P, Berardelli A. Botulinum toxin A treatment for primary hemifacial spasm: a 10-year multicenter study. Arch Neurol. 2002 Mar;59(3):418-20. 28. Berardelli A(1), Formica A, Mercuri B, Abbruzzese G, Agnoli A, Agostino R,Caraceni T, Carella F, De Fazio G, De Grandis D, et al. Botulinum toxin treatment in patients with focal dystonia and hemifacial spasm. A multicenter study of the Italian Movement Disorder Group. Ital J Neurol Sci. 1993 Jun;14(5):361-7.

XI. Appendix:

Medicare Part B Administrative Contractor (MAC) Jurisdictions Jurisdiction Applicable State/US Territory Contractor

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Botulinum Toxins Medical Necessity Criteria Last Review Date: 03/25/2014 Number: IC-0022

E CA,HI, NV, AS, GU, CNMI Noridian Administrative Services (NAS) F AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ Noridian Administrative Services (NAS) 5 KS, NE, IA, MO Wisconsin Physicians Service (WPS) 6 MN, WI, IL National Government Services (NGS) H LA, AR, MS, TX, OK, CO, NM Novitas Solutions 8 MI, IN Wisconsin Physicians Service (WPS) 9 (N) FL, PR, VI First Coast Service Options 10 (J) TN, GA, AL Cahaba Government Benefit Administrators 11 (M) NC, SC, VA, WV Palmetto GBA 12 (L) DE, MD, PA, NJ, DC Novitas Solutions K NY, CT, MA, RI, VT, ME, NH National Government Services (NGS) 15 KY, OH CGS Administrators, LLC

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