CLV IntelligenceReimbursement Policy Evidence

Medicare prior authorization · J0586

J0586 — Botulinum Toxin Injection

Subject to the hospital outpatient department prior authorization program nationwide when furnished in a hospital outpatient department. Subject to CMS’s ASC prior authorization demonstration when furnished in an ambulatory surgical center in CA, FL, TN, PA, MD, GA, NY, TX, AZ, OH. The decision is made on Medicare’s existing coverage policy; nothing in these programs changes what is covered.

The coverage policy the reviewer applies, by contractor

CMS publishes no policy references for this program’s code list. The policies below are the ones whose own procedure-code tables list J0586 — matched by CLV analysis; the linked CMS document is authoritative. Each state’s contractor writes its own, so the policy that decides a request depends on the state.

Noridian · 16 states: AK, AS, AZ, CA, GU, HI, ID, MP, MT, ND, NV, OR, SD, UT, WA, WY

  • L35170 — Botulinum Toxin Injections — Noridian · CMS version 60 · captured 2026-07-25
  • L35172 — Botulinum Toxin Injections — Noridian · CMS version 72 · captured 2026-07-25

This contractor publishes more than one policy listing J0586, and the capture records the contractor rather than the jurisdiction — so which one governs depends on the jurisdiction serving the state. Run the check for your state.

Novitas · 12 states: AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX

  • L38809 — Botulinum Toxins — Novitas · CMS version 30 · captured 2026-07-24

Read the documentation requirements in the linked CMS document.

National Government Services · 10 states: CT, IL, MA, ME, MN, NH, NY, RI, VT, WI

  • L33646 — Botulinum Toxins — NGS · CMS version 40 · captured 2026-07-27
  • L39832 — Botulinum Toxin Injections — NGS · CMS version 13 · captured 2026-07-25

This contractor publishes more than one policy listing J0586, and the capture records the contractor rather than the jurisdiction — so which one governs depends on the jurisdiction serving the state. Run the check for your state.

Palmetto GBA · 7 states: AL, GA, NC, SC, TN, VA, WV

  • L33458 — Chemodenervation — Palmetto GBA · CMS version 70 · captured 2026-07-27
  • L39836 — Botulinum Toxin Injections — Palmetto GBA · CMS version 8 · captured 2026-07-26

This contractor publishes more than one policy listing J0586, and the capture records the contractor rather than the jurisdiction — so which one governs depends on the jurisdiction serving the state. Run the check for your state.

WPS · 6 states: IA, IN, KS, MI, MO, NE

  • L34635 — Botulinum Toxin Type A & Type B — WPS · CMS version 37 · captured 2026-07-27
  • L39909 — Botulinum Toxin Injections — WPS · CMS version 6 · captured 2026-07-28

This contractor publishes more than one policy listing J0586, and the capture records the contractor rather than the jurisdiction — so which one governs depends on the jurisdiction serving the state. Run the check for your state.

First Coast · 3 states: FL, PR, VI

  • L33274 — Botulinum Toxins — First Coast · CMS version 43 · captured 2026-07-24

Read the documentation requirements in the linked CMS document.

CGS Administrators · 2 states: KY, OH

  • L33949 — Botulinum Toxins — CGS · CMS version 26 · captured 2026-07-27
  • L39857 — Botulinum Toxin Injections — CGS · CMS version 7 · captured 2026-07-26

This contractor publishes more than one policy listing J0586, and the capture records the contractor rather than the jurisdiction — so which one governs depends on the jurisdiction serving the state. Run the check for your state.

Hospital-OPD prior authorization program

Where
nationwide, hospital outpatient department only
Decision
7 calendar days; 2 business days expedited
Coverage policy
the MAC’s LCD for the state — the check below finds it
CMS note
Since 2020-07-01.

ASC prior authorization demonstration

Where and from when
ambulatory surgical center only; CA, FL, TN, PA, MD, GA, NY for dates of service on or after 2026-01-19; TX, AZ, OH for dates of service on or after 2026-02-16
Decision
7 calendar days; 2 business days expedited; valid 120 days
If no request is made
prior authorization is voluntary; the claim is stopped for prepayment medical record review
Submit
the ASC submits to its MAC by mail, fax, esMD (content type 8.7) or the MAC’s portal
Exemption
not yet published: “CMS will provide further information regarding exemption.”

Check J0586 for your state, diagnosis and setting

The governing policy as it stands today, whether the diagnosis is on its list, and the documentation the policy’s own text requires — quoted, source-linked, free.

Run the check →

Full lists: hospital outpatient code list · ASC demonstration code list

Same family: 64612 · 64615 · J0585 · J0587 · J0588 · J0589

Sources: CMS WISeR Provider and Supplier Operational Guide v7.0 (2026-07-24), Appendix A; CMS list of OPD services requiring prior authorization (2024-08-05); CMS list of ambulatory surgical center services for prior authorization (2026-03-05) and the ASC Operational Guide (2026-03-03). Codes are shown as numbers only, as CMS lists them. CPT® is a registered trademark of the American Medical Association.