NANOSNET

Botulinum Toxin MAC Policy Update - Key Takeaways for Neuro-Ophthalmologists

Five Medicare Administrative Contractors-CGS Administrators, National Government Services, Noridian Healthcare Solutions, Palmetto GBA, and Wisconsin Physicians Service-implemented updated policies for botulinum toxin injections effective Feb. 22. These policies affect treatments commonly used in neuro-ophthalmology, including Blepharospasm, Hemifacial Spasm, and Strabismus.

Additional billing and documentation guidance has been released by the American Academy of Ophthalmology and with permission are accessible here. Members are encouraged to review these resources and the summary document available in the Practice Support Tools section of the North American Neuro-Ophthalmology Society website.

Key Policy Point

A critical provision in the new policies states that if botulinum toxin is used for a covered diagnosis but also administered with cosmetic intent, the entire claim may be considered not reasonable and necessary and therefore non-covered.

Practical Implications

Physicians should be aware that:

• There will likely be increased scrutiny of botulinum toxin billing.
• Advance Beneficiary Notices (ABNs) may be needed for Medicare patients when treatment may fall outside coverage criteria.
• Medicare may recoup payments if claims are later determined to have been billed incorrectly, potentially requiring physicians to repay previously issued reimbursements.

Advocacy Update

Advocacy efforts are ongoing to address these policy concerns. Leadership from the North American Neuro-Ophthalmology Society has worked alongside the American Academy of Ophthalmology and the American Society of Ophthalmic Plastic and Reconstructive Surgery to push back on these policies since before 2024. Despite these efforts, the policies were ultimately finalized.