01/21/2026

WPS Oncology Related LCD Updates

New Policy Updates

Botulinum Toxin Injections: New Policy Update

The Local Coverage Determination (LCD) DL39909 for Botulinum Toxin Injections will start on January 1, 2026. The new policy will take effect on February 15, 2026. WPS worked with other MACs to create this update.

The use of Botulinum toxin to treat conditions is growing. This new LCD addresses the need to update our current policy with the latest evidence and practice guidance.  

Why Is This Important?

This new policy covers more than a dozen different conditions as well as multiple medical specialties and practice types. The policy includes over 330 articles and resources that support the changes.

You should know that the MACs received and reviewed thousands of comments during the open comment period. These comments helped shape the policy changes.

Because this policy could change how Botox services are approved and paid for, you need to stay informed. Following the new guidelines will help avoid claim denials.

What You Need to Do

After you read the Coverage Guidance, focus on the conditions you treat most often. Pay attention to the following details for each condition:

• LCD requirements
• Treatment plans
• Toxin type
• Initial and follow-up doses
• Injection sites
• Treatment frequency

You will also need to document progress with an objective scale at each visit. This helps show how the treatment works.

Make sure to keep clear records if you change a patient’s treatment plan. This includes things like increasing the dose or changing how often you inject Botox.

Who Is Affected?

The biggest impact will be on Hospital Outpatient Departments (HOPDs) and Physicians who are involved in Prior Authorization (PA). You need to prepare for changes in the way Botox claims are processed. These changes will directly affect PA requests for specific CPT codes:

• 64612:chemodenervation of muscles innervated by facial nerve, e.g., blepharospasm, hemifacial spasm.
• 64615:chemodenervation of muscles innervated by facial, trigeminal, cervical spinal and accessory nerves, e.g. for chronic migraine

Next Steps

If your hospital or practice provides Botox services that are part of Medicare’s prior authorization process, make sure you attend the WPS webinar about these changes. It is important to understand the new rules to avoid payment delays or denials.

Webinar: Hospital Outpatient Departments & Physicians: Prepare for Critical LCD Changes that Affect Botox Prior Authorization

Date: Thursday, January 22, 2026

Time: 2:00 - 3:30 pm CT (3:00 – 4:30 pm ET)

Key Changes to Remember

• LCD DL39909 for Botulinum Toxin Injections starts January 1, 2026, with full implementation by February 15, 2026.
• The policy covers many conditions, medical specialties, and practice types.
• Multi-MAC collaboration reviewed thousands of comments to shape the policy.
• Prior Authorization (PA) process will change in Hospital Outpatient Department (HOPD) of Prospective Payment System (PPS) hospitals for certain conditions.
• Providers must update documentation and follow the new LCD requirements for each condition treated.

Summary

Stay up to date on these changes to make sure your Botox claims are processed smoothly. Follow the new guidelines for each condition, make the required changes to documentation, and keep your focus on patient care.

January 2026 Local Coverage Determination (LCD) and Billing and Coding Article Updates

We updated the following Local Coverage Determinations (LCDs) and Billing and Coding Articles for January 2026. The full article on our website details additional information on these updates.  

Please note: Our LCDs and Billing and Coding/Coverage articles will reflect these changes on January 1, 2026.

New Policies/Articles – New Policies/Articles – We created no new policies/articles for January 2026.

Retired Policies/Articles – We retired no policies/articles for January 2026.

Revised Policies/Articles – We revised the following policies/articles for January 2026 –Effective as Indicated 

Billing and Coding: Autonomic Function Testing – Effective January 1, 2026 

Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea – Effective January 1, 2026 

Billing and Coding: Implantable Automatic Defibrillators – Effective January 1, 2026

Billing and Coding: MolDx: Minimal Residual Disease Testing for Solid Tumor Cancers – Effective December 18, 2025

Billing and Coding: MolDx: Pik3ca Gene Tests – Effective January 1, 2026

Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker – Effective January 1, 2026

Urine Drug Testing – Effective January 1, 2026