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Contractor Information

Contractor Name: Noridian Healthcare Solutions, LLC - Full list of policies of this Medicare Contractor Contractor Number: 01112 Contractor Type: MAC B

LCD Information

LCD ID Number: L35170 Status: A-Approved LCD Title: Botulinum Toxin Injections Geographic Jurisdiction: California - Northern Other Jurisdictions Original Determination Effective Date: 10/01/2015 Original Determination Ending Date: Revision Effective Date: 02/22/2026 Revision End Date: CMS National Coverage Policy: Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1862(a)(10) excludes coverage for cosmetic surgery. Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Code of Federal Regulations: 42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements)who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter). CMS Publications: CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 8: 50.5 Drugs and Biologicals [Coverage of SNF services] 70 Medical and Other Health Services Furnished to SNF Patients. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 12: 40.10 Drugs and Biologicals [Coverage of Comprehensive Outpatient Rehabilitation Facility services] CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15: 50.1–50.5 Drugs and Biologicals 120 Ambulatory Surgical Center Services CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16: 260 Non-coverage for Cosmetic Procedures CMS Publication 100-04; Medicare Claims Processing Manual, Chapter 17: 40 Discarded Drugs and Biologicals CMS Publication 100-04; Medicare Claims Processing Manual, Chapter 30: 20.2.1 Categorical Denials Sorry, you need to login or register to view additional sections of this Medicare policy. *