Aetna modified CPB 0113 covering botulinum toxin products, effective February 11, 2026. Here's what billing teams need to know before submitting another claim.
Aetna, a CVS Health company, updated its botulinum toxin coverage policy (CPB 0113) governing Botox (onabotulinumtoxinA), Daxxify (daxibotulinumtoxinA-lanm), Dysport (abobotulinumtoxinA), Myobloc (rimabotulinumtoxinB), and Xeomin (incobotulinumtoxinA). This update touches dozens of CPT and HCPCS codes — including J0585, J0586, J0587, J0588, and J0589 for the drug products themselves, and procedure codes like 64612, 64615, 64616, 52287, and 64650 for the injections. If your practice bills botulinum toxin for any indication beyond cosmetic use, this policy affects your reimbursement.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Botulinum Toxin — CPB 0113 |
| Policy Code | CPB 0113 |
| Change Type | Modified |
| Effective Date | February 11, 2026 |
| Impact Level | High |
| Specialties Affected | Neurology, Urology, Gastroenterology, Ophthalmology, Physical Medicine & Rehabilitation, Head & Neck Surgery, Dermatology, Psychiatry |
| Key Action | Verify medical necessity documentation and precertification for all five botulinum toxin products before submitting claims under CPB 0113 |
Aetna Botulinum Toxin Coverage Criteria and Medical Necessity Requirements 2026
The Aetna botulinum toxin coverage policy applies to commercial medical plans only. Medicare criteria live separately on Aetna's Medicare Part B page — don't conflate the two when you're working up authorizations.
Precertification is required across the board. All five products — Botox, Daxxify, Dysport, Myobloc, and Xeomin — require precertification from all Aetna participating providers in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277 to initiate. If your team isn't running prior authorization on every botulinum toxin claim against an Aetna commercial plan, you're already exposed to claim denial.
The policy requires that the prescribing provider either specializes in treating the member's condition or consults with one who does. This isn't just a documentation checkbox — Aetna can use this to deny claims where the prescriber specialty doesn't match the indication. Make sure your authorization requests reflect the treating provider's relevant specialty.
OnabotulinumtoxinA (Botox) — Medical Necessity Criteria by Indication
Aetna considers Botox medically necessary for a defined list of indications. Each carries its own criteria. The major ones your billing team needs to know:
Chronic migraine (CPT 64615): The member must have headaches on 15 or more days per month, lasting four hours or longer on at least eight of those days. They also need a documented, adequate trial of two migraine preventive therapies from at least two drug classes — each trial at least 60 days long. The source policy lists antidepressants and antiepileptics as confirmed drug classes; the full class list is defined in the complete policy. Missing any one of the documented criteria means a denied claim.
Overactive bladder / neurogenic detrusor overactivity (CPT 52287): Aetna covers bladder chemodenervation via cystourethroscopy (CPT 52287) when members have tried and failed appropriate first-line therapies. Document the failed trials explicitly in your prior auth request.
Cervical dystonia (CPT 64616): Members must be 18 or older and show abnormal head placement with limited range of motion. Both criteria must be documented.
Blepharospasm (CPT 64612): Members must be 12 or older and carry a diagnosis of blepharospasm — including blepharospasm associated with dystonia, benign essential blepharospasm, or VII nerve disorder.
Hyperhidrosis (CPT 64650, 64653): CPT 64650 covers both axillae; CPT 64653 covers other areas like the scalp, face, or neck. For the specific prior-treatment requirements under each hyperhidrosis indication, refer to the full policy text — the source data provided does not include the complete criteria language for this section.
Sialorrhea (CPT 64611): Chronic sialorrhea requires documented failure of pharmacotherapy, specifically anticholinergics, before Aetna considers Botox medically necessary.
Spasticity (CPT 64642–64647): Upper and lower limb spasticity and trunk spasticity are covered indications. Codes 64642, 64643, 64644, and 64645 cover extremity chemodenervation; 64646 and 64647 cover trunk muscles. For the specific medical necessity criteria — including documentation requirements — refer to the full policy text, as the source data provided does not include the complete criteria language for this section.
The pattern throughout this policy is consistent: failed first-line therapy, documented diagnosis, age criteria where applicable, and specialist prescriber. If your documentation doesn't show all of these, expect a denial.
Aetna Botulinum Toxin Exclusions and Non-Covered Indications
Aetna explicitly excludes botulinum toxin for cosmetic use. This applies to all five products. There is no coverage pathway for cosmetic indications under CPB 0113, regardless of clinical framing.
Beyond cosmetics, CPT codes 43107 through 43124 — covering total or near-total esophagectomy — are not covered under this policy for any indication listed in CPB 0113. These are surgical codes, not injection codes, but they appear in the policy's exclusion list. If your gastroenterology or thoracic surgery team bundles any of these with botulinum toxin claims, flag that combination for review.
CPT 86609, which covers antibody testing for neutralizing antibodies to botulinum toxin, is also listed as not covered. Don't bill this alongside your injection claims expecting reimbursement under this policy.
CPT 76942 (ultrasonic guidance for needle placement) is listed under codes not covered when selection criteria are met. Flag this if your providers use ultrasound guidance for botulinum toxin injections — that guidance code won't be separately reimbursable under this policy.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Chronic migraine prophylaxis | Covered | 64615, J0585 | 15+ headache days/month; 4+ hrs on 8+ days; 2 failed drug class trials, 60 days each |
| Cervical dystonia | Covered | 64616, J0585 | Adults 18+; abnormal head placement with limited ROM required |
| Blepharospasm | Covered | 64612, J0585 | Age 12+; dystonia, benign essential, or VII nerve disorder diagnosis |
| Upper/lower limb spasticity | Covered | 64642–64645, J0585/J0586/J0588 | See full policy for medical necessity criteria |
| Trunk muscle spasticity | Covered | 64646, 64647, J0585 | See full policy for medical necessity criteria |
| Overactive bladder / neurogenic detrusor overactivity | Covered | 52287, J0585 | Failed first-line therapies required |
| Primary axillary hyperhidrosis | Covered | 64650, J0585 | See full policy for prior-treatment criteria |
| Hyperhidrosis (other areas) | Covered | 64653, J0585 | Scalp, face, neck; per day |
| Chronic sialorrhea | Covered | 64611, J0585 | Failed anticholinergics |
| Achalasia | Covered | 43192, 43201, 43236, 43253, J0585 | Failed or poor candidate for pneumatic dilation or myotomy |
| Chronic anal fissure | Covered | 46505, J0585 | Failed topical calcium channel blockers or nitrates |
| Spasmodic dysphonia | Covered | 64617, S2340, S2341, J0585 | Laryngeal chemodenervation; EMG guidance included |
| Vocal cord injection (other) | Covered | 31513, 31570, 31571, J0585 | Laryngoscopy-guided |
| Hemifacial spasm | Covered | J0585 | Prior auth required; see full policy for procedure code mapping |
| Focal hand dystonia | Covered | J0585 | Prior auth required; see full policy for procedure code mapping |
| Essential tremor | Covered | J0585 | Prior auth required; see full policy for procedure code mapping |
| Facial myokymia | Covered | J0585 | Prior auth required; see full policy for procedure code mapping |
| First bite syndrome | Covered | J0585 | Failed analgesics, antidepressants, or anticonvulsants |
| Hirschsprung disease with internal sphincter achalasia | Covered | 46505, J0585 | Post-endorectal pull-through; refractory to laxatives |
| Cosmetic use (any product) | Not Covered | — | All five products excluded |
| Esophagectomy procedure codes (43107–43124) | Not Covered | 43107–43124 | Not covered for any listed indication |
| Neutralizing antibody testing | Not Covered | 86609 | Listed as not covered under CPB 0113 |
| Ultrasound guidance for injection | Not Covered | 76942 | Not separately reimbursable under this policy |
Aetna Botulinum Toxin Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Run precertification on every botulinum toxin claim before February 11, 2026. All five products require prior authorization under Aetna commercial plans. Call (866) 752-7021 or fax your Statement of Medical Necessity to (888) 267-3277. If you're not already running this workflow, build it now. |
| 2 | Audit your charge capture for guidance add-on codes. CPT 95873 (electrical stimulation guidance) and CPT 95874 (needle EMG guidance) are covered as add-ons when chemodenervation meets criteria. CPT 76942 (ultrasound guidance) is not covered. Update your charge capture rules to exclude 76942 from botulinum toxin injection claims and to correctly append 95873 or 95874 where documented. |
| 3 | Document failed first-line therapies explicitly in every authorization request. Nearly every indication in this policy requires proof of failed prior treatment. For chronic migraine, that means two drug classes, 60-day trials each — refer to the full policy for the confirmed class list. For sialorrhea, that means failed anticholinergics. Don't assume the clinical notes will speak for themselves — summarize the failed trials in the auth request. |
| 4 | Verify prescriber specialty alignment with the indication. Aetna requires the prescribing provider to specialize in treating the member's condition. A urologist billing 52287 for bladder overactivity is fine. A primary care provider billing 64615 for chronic migraine without neurology consultation is a denial risk. Check your prescriber-to-indication mapping before submitting. |
| 5 | Separate cosmetic and medical botulinum toxin billing completely. If your practice offers both cosmetic and medical botulinum toxin services, your billing system must have a hard separation between the two. There is no coverage pathway for cosmetic use under CPB 0113. Any cosmetic claim that bleeds into a medical claim creates audit exposure. |
| 6 | Flag mixed claims involving esophagectomy CPT codes. If your gastroenterology or thoracic surgery team ever co-bills esophagectomy codes (43107–43124) with botulinum toxin codes on the same claim, the botulinum toxin portion may be denied. Review your claim scrubber rules for this combination. |
| 7 | Talk to your compliance officer if your mix includes off-label indications. CPB 0113 covers a defined list. If your providers are using botulinum toxin for indications not listed in this policy — and billing them to Aetna commercial plans — you need a compliance review before the effective date of February 11, 2026. |
| 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), therapeutic; 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); 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 muscle(s); 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 |
| 64643 | CPT | Chemodenervation of one extremity |
| 64644 | CPT | Chemodenervation of one extremity |
| 64645 | CPT | Chemodenervation of one extremity |
| 64646 | CPT | Chemodenervation of trunk muscle(s) |
| 64647 | CPT | Chemodenervation of trunk muscle(s) |
| 64650 | CPT | Chemodenervation of eccrine glands; both axillae |
| 64653 | CPT | Chemodenervation of eccrine glands; other area(s) (e.g., scalp, face, neck), 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) |
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 |
Not Covered / Excluded 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 met |
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 / E11.40–E11.49 / E13.40–E13.49 | Diabetes with neurological complications (gastroparesis, diabetic neuropathic pain) |
| 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 rows above represent a sample from the policy data provided. For the full diagnosis code list, access the complete policy at PayerPolicy.org.
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