Aetna modified CPB 0113 for botulinum toxin, effective February 11, 2026. Here's what billing teams need to know before submitting claims under J0585, J0586, J0587, J0588, or J0589.
Aetna, a CVS Health company, updated Clinical Policy Bulletin 0113 covering botulinum toxin products — including Botox (onabotulinumtoxinA), Dysport (abobotulinumtoxinA), Myobloc (rimabotulinumtoxinB), Xeomin (incobotulinumtoxinA), and Daxxify (daxibotulinumtoxinA-lanm). This coverage policy spans more than 48 CPT codes and nine HCPCS drug codes, touching specialties from neurology and urology to gastroenterology and ophthalmology. If your practice bills any chemodenervation procedures or botulinum toxin injections to Aetna commercial plans, this update affects your prior authorization workflow, medical necessity documentation, and claim submission process.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna (CPB 0113) |
| Policy | Botulinum Toxin — CPB 0113 | Aetna Coverage Update |
| Policy Code | CPB 0113 |
| Change Type | Modified |
| Effective Date | February 11, 2026 |
| Impact Level | High |
| Specialties Affected | Neurology, Urology, Gastroenterology, Ophthalmology, ENT, Physical Medicine & Rehabilitation, Pain Management, Dermatology |
| Key Action | Verify precertification is on file for all botulinum toxin claims before billing J0585–J0589 on Aetna commercial plans |
Aetna Botulinum Toxin Coverage Criteria and Medical Necessity Requirements 2026
The Aetna botulinum toxin coverage policy under CPB 0113 Aetna system covers five drug products across a wide range of indications. Every one of them requires precertification. No exceptions.
To get precertification, call (866) 752-7021 or fax your Statement of Medical Necessity form to (888) 267-3277. If you're not already routing botulinum toxin requests through this channel, fix that now. Claims without prior authorization will deny — and retro-authorization is not guaranteed.
The prescriber must specialize in treating the member's condition. A neurologist prescribing for cervical dystonia is fine. A general internist ordering Botox for spasticity without a specialist co-signature is a problem. Document that prescriber qualification in every chart.
OnabotulinumtoxinA (Botox, HCPCS J0585) — Medical Necessity Criteria
Aetna considers J0585 medically necessary for a long list of indications. The key step-edit and failure requirements differ by condition. Here are the ones most likely to generate claim denials when documentation is incomplete:
Chronic migraine (the highest-volume indication): The member must have headaches 15 or more days per month, with at least eight of those days lasting four or more hours. Before approving Botox, Aetna requires a documented adequate trial — at least 60 days each — of two preventive therapies from at least two different drug classes. Those classes include antidepressants (e.g., amitriptyline, venlafaxine), antiepileptics, beta-blockers, and calcium channel blockers.
This is a hard stop. If your neurologist is prescribing Botox for migraine and the chart doesn't show those two prior medication trials with documented duration, the prior authorization will be denied. Build a checklist for your clinical staff.
Cervical dystonia (CPT 64615, 64616): The member must show abnormal head placement with limited neck range of motion, and must be 18 or older. Both criteria must be met. Document range-of-motion findings explicitly — "torticollis" in the diagnosis field alone doesn't close that loop.
Blepharospasm (CPT 64612): Member must be 12 or older with a confirmed diagnosis of blepharospasm, including benign essential blepharospasm, dystonia-associated blepharospasm, or VII nerve disorder.
Chronic sialorrhea (CPT 64611): The member must have failed pharmacotherapy, including anticholinergics. Document that failure specifically — generic "medication intolerance" isn't enough.
Overactive bladder and neurogenic detrusor overactivity (CPT 52287): For overactive bladder, the member must have tried and failed an adequate trial of at least two anticholinergic or beta-3 agonist medications. For neurogenic detrusor overactivity, the member must have tried and failed catheterization or antimuscarinic therapy.
Upper and lower limb spasticity (CPT 64642–64645, 64646–64647): The policy requires documentation of functional impairment and prior non-injection therapies (e.g., physical therapy, oral antispasmodics). Spasticity is a high-volume indication — make sure your rehab and neurology teams understand the step-edit requirements.
Achalasia (CPT 43236, 43201, 43253): Member must have tried and failed pneumatic dilation or surgical myotomy, or be a poor candidate for conventional therapy.
Chronic anal fissure (CPT 46505): First-line therapies — topical calcium channel blockers or topical nitrates — must have failed. This code is specifically covered for anal fissure only under this policy.
AbobotulinumtoxinA (Dysport, HCPCS J0586), IncobotulinumtoxinA (Xeomin, J0588), RimabotulinumtoxinB (Myobloc, J0587), and DaxibotulinumtoxinA-lanm (Daxxify, J0589)
These products have narrower covered indications than Botox. Dysport and Xeomin cover cervical dystonia and upper limb spasticity. Myobloc covers cervical dystonia. Daxxify covers cervical dystonia and upper limb spasticity in adults. Each product has specific age and clinical criteria — don't assume that an approval for J0585 automatically covers a switch to J0588. Reimbursement and approval are product-specific.
Aetna Botulinum Toxin Exclusions and Non-Covered Indications
Aetna explicitly excludes cosmetic use. Full stop. Any claim for Botox or related products for aesthetic purposes — glabellar lines, facial rejuvenation, hyperhidrosis for cosmetic reasons — is not covered under commercial medical plans. If a member wants cosmetic Botox, it's out-of-pocket. Don't bill it.
CPT 86609 (neutralizing antibody testing to botulinum toxin) is not covered under this policy. If a member develops resistance and the treating provider orders antibody testing, don't expect reimbursement. Same goes for CPT 76942 (ultrasound guidance for needle placement) — it is listed as not covered if selection criteria are met, which means guidance-assisted injection billing gets denied when the underlying procedure doesn't meet criteria first.
The esophagectomy codes (CPT 43107 through 43124) are explicitly listed as not covered for the indications in this CPB. Those are surgical resection codes, not injection codes — they appear here because achalasia is an overlapping condition. Don't let a coder accidentally pull them into a botulinum toxin claim.
Coverage Indications at a Glance
| Indication | Status | Key CPT/HCPCS | Notes |
|---|---|---|---|
| Chronic migraine | Covered | J0585 | ≥15 headache days/month; ≥2 failed preventive drug classes (60 days each) |
| Cervical dystonia | Covered | J0585, J0586, J0587, J0588, J0589; CPT 64615, 64616 | Abnormal head placement, limited ROM, age ≥18 |
| Upper limb spasticity | Covered | J0585, J0586, J0588, J0589; CPT 64642, 64643 | Functional impairment required; prior therapy documentation |
| Lower limb spasticity | Covered | J0585; CPT 64644, 64645 | Same functional impairment and prior therapy criteria |
| Trunk spasticity | Covered | J0585; CPT 64646, 64647 | Documentation of functional impairment required |
| Blepharospasm | Covered | J0585; CPT 64612 | Age ≥12; confirmed diagnosis |
| Overactive bladder | Covered | J0585; CPT 52287 | Failed ≥2 anticholinergic or beta-3 agonist agents |
| Neurogenic detrusor overactivity | Covered | J0585; CPT 52287 | Failed catheterization or antimuscarinic therapy |
| Chronic sialorrhea | Covered | J0585; CPT 64611 | Failed anticholinergics |
| Achalasia | Covered | J0585; CPT 43236, 43201, 43253 | Failed/poor candidate for pneumatic dilation or myotomy |
| Chronic anal fissure | Covered | J0585; CPT 46505 | Failed topical CCBs or nitrates; CPT 46505 covered for this indication only |
| Hemifacial spasm | Covered | J0585; CPT 64612 | No step-edit listed |
| Essential tremor | Covered | J0585 | No step-edit listed |
| Spasmodic dysphonia | Covered | J0585; CPT 64617, S2340, S2341 | Laryngeal injection procedures |
| Focal hand dystonia | Covered | J0585 | No step-edit listed |
| Hyperhidrosis (axillary) | Covered | J0585; CPT 64650 | Failed topical antiperspirants and systemic agents |
| Facial myokymia | Covered | J0585 | No step-edit listed |
| First bite syndrome | Covered | J0585 | Failed analgesics, antidepressants, or anticonvulsants |
| Cosmetic use | Not Covered | Any | Explicit exclusion across all products |
| Neutralizing antibody testing | Not Covered | CPT 86609 | Not covered under this CPB |
| Ultrasound guidance (when criteria not met) | Not Covered | CPT 76942 | Covered only when underlying procedure meets criteria |
| Esophagectomy codes | Not Covered | CPT 43107–43124 | Not applicable to botulinum toxin indications |
Aetna Botulinum Toxin Billing Guidelines and Action Items 2026
This policy has a lot of moving parts. Here's what to do before you submit another botulinum toxin claim on an Aetna commercial plan.
| # | Action Item |
|---|---|
| 1 | Audit your precertification queue now. The effective date is February 11, 2026. Any claim for J0585, J0586, J0587, J0588, or J0589 on an Aetna commercial plan needs precertification on file. Pull a report of upcoming botulinum toxin appointments and confirm auth status for each. |
| 2 | Build indication-specific documentation templates. The failure criteria differ by indication. Chronic migraine needs 60-day drug trial documentation. Overactive bladder needs two failed agents documented. Your prior auth team should not be hunting for this information at submission time — it should be in a structured note template your providers complete before ordering. |
| 3 | Verify prescriber specialty match. Aetna requires the prescriber to specialize in the condition being treated. If your practice uses a shared ordering workflow, confirm the ordering provider's specialty aligns with the diagnosis. Document the specialist consultation if the ordering provider is a generalist. |
| 4 | Separate cosmetic from medical Botox at charge capture. Your charge capture system should flag any botulinum toxin claim without a qualifying medical diagnosis code. Cosmetic use is not covered. A coding error that routes a cosmetic case through the medical benefit is a compliance problem, not just a claim denial risk. |
| 5 | Check guidance billing against underlying procedure approval. CPT 95873 (electrical stimulation guidance) and CPT 95874 (needle EMG guidance) are covered add-on codes when the primary chemodenervation procedure meets criteria. CPT 76942 (ultrasound guidance) is not covered if the underlying procedure doesn't meet criteria. Don't bill guidance codes on a claim where the primary procedure is itself at risk of denial. |
| 6 | Reconcile drug code to product. J0585 is Botox, J0586 is Dysport, J0587 is Myobloc, J0588 is Xeomin, J0589 is Daxxify. Each product has different covered indications under this policy. A formulary substitution mid-treatment may invalidate an existing authorization. Confirm with your specialty pharmacy team when product switches happen. |
| 7 | Loop in your compliance officer if you bill across multiple Aetna plan types. This CPB applies to commercial plans only. Medicare criteria are handled separately. If your practice mixes Aetna commercial and Aetna Medicare Advantage patients, make sure your billing team applies the right criteria to each population. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Botulinum Toxin Under CPB 0113
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 31513 | CPT | Laryngoscopy, with vocal cord injection |
| 31570 | CPT | Laryngoscopy, direct, with injection into vocal cord(s), therapeutic |
| 31571 | CPT | Laryngoscopy, direct, with injection into vocal cord(s); with operating microscope or telescope |
| 43192 | CPT | Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance |
| 43201 | CPT | Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance |
| 43236 | CPT | Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance |
| 43253 | CPT | Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance |
| 46505 | CPT | Chemodenervation of internal anal sphincter [covered for anal fissure only] |
| 52287 | CPT | Cystourethroscopy, with injection(s) for chemodenervation of the bladder |
| 64611 | CPT | Chemodenervation of parotid and submandibular salivary glands, bilateral |
| 64612 | CPT | Chemodenervation of muscle(s) innervated by facial nerve, unilateral |
| 64615 | CPT | Chemodenervation of muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral |
| 64616 | CPT | Chemodenervation of neck muscle(s), excluding muscles of the larynx, unilateral |
| 64617 | CPT | Chemodenervation of larynx, unilateral, percutaneous; includes guidance by needle electromyography |
| 64642 | CPT | Chemodenervation of one extremity; 1–4 muscles |
| 64643 | CPT | Chemodenervation of one extremity; each additional extremity, 1–4 muscles (add-on) |
| 64644 | CPT | Chemodenervation of one extremity; 5 or more muscles |
| 64645 | CPT | Chemodenervation of one extremity; each additional extremity, 5 or more muscles (add-on) |
| 64646 | CPT | Chemodenervation of trunk muscle(s); 1–5 muscles |
| 64647 | CPT | Chemodenervation of trunk muscle(s); 6 or more muscles |
| 64650 | CPT | Chemodenervation of eccrine glands; both axillae |
| 64653 | CPT | Chemodenervation of eccrine glands; other area(s), per day |
| 67345 | CPT | Chemodenervation of extraocular muscle |
| +95873 | CPT | Electrical stimulation for guidance in conjunction with chemodenervation (add-on) |
| +95874 | CPT | Needle electromyography for guidance in conjunction with chemodenervation (add-on) |
| 96372 | CPT | Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular |
Not Covered CPT Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 43107 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43108 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43109 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43110 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43111 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43112 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43113 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43114 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43115 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43116 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43117 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43118 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43119 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43120 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43121 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43122 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43123 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 43124 | CPT | Total or near total esophagectomy | Not covered for indications listed in CPB 0113 |
| 86609 | CPT | Antibody; bacterium, not elsewhere specified [neutralizing antibodies to botulinum toxin] | Not covered for indications listed in CPB 0113 |
| 76942 | CPT | Ultrasonic guidance for needle placement | Not covered when selection criteria are not met |
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| J0585 | HCPCS | Botulinum toxin type A, per unit [Botox / onabotulinumtoxinA] |
| J0586 | HCPCS | Injection, abobotulinumtoxinA, 5 units [Dysport] |
| J0587 | HCPCS | Botulinum toxin type B, per 100 units [Myobloc / rimabotulinumtoxinB] |
| J0588 | HCPCS | Injection, incobotulinumtoxinA, 1 unit [Xeomin] |
| J0589 | HCPCS | Injection, daxibotulinumtoxinA-lanm, 1 unit [Daxxify] |
| D9913 | HCPCS | Administration of neuromodulators |
| S2340 | HCPCS | Chemodenervation of abductor muscle(s) of vocal cord |
| S2341 | HCPCS | Chemodenervation of adductor muscle(s) of vocal cord |
Other Related HCPCS
| Code | Type | Description | Notes |
|---|---|---|---|
| J3031 | HCPCS | Injection, fremanezumab-vfrm, 1 mg | Listed in context of CGRP migraine agents; no specific coverage criteria listed within CPB 0113 |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| B02.29 | Other postherpetic nervous system involvement (postherpetic neuralgia) |
| D29.1 | Benign neoplasm of prostate |
| E05.0 | Thyrotoxicosis with diffuse goiter (Graves ophthalmopathy) |
| E05.1 | Thyrotoxicosis with toxic single thyroid nodule (Graves ophthalmopathy) |
| E10.40–E10.49 | Type 1 diabetes with diabetic neuropathy (gastroparesis, diabetic neuropathic pain) |
| E11.40–E11.49 | Type 2 diabetes with diabetic neuropathy |
| E13.40–E13.49 | Other diabetes with diabetic neuropathy |
| E66.1–E66.9 | Overweight and obesity |
| F32.0–F33.9 | Major depressive disorder |
| F34.1 | Dysthymic disorder |
| F43.21 | Adjustment disorder with depressed mood |
| F43.23 | Adjustment disorder with mixed anxiety and depressed mood |
| F95.1 | Chronic motor or vocal tic disorder |
| F95.2 | Tourette's disorder |
| F98.5 | Adult onset fluency disorder |
| G11.4 | Hereditary spastic paraplegia (limb spasticity) |
| G20.B1–G20.B2 | Parkinson's disease (Parkinson's disease dystonia) |
Note: CPB 0113 references 1,268 ICD-10-CM codes in total. The codes above represent key diagnoses listed in the policy data. For the full ICD-10 code list, access the complete policy at PayerPolicy.org.
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