CPT 64642, in plain terms, covers Botulinum toxin chemodenervation of one arm or leg, injecting 1 to 4 muscles. CPT 64642 is referenced in 7 tracked payer policy changes from UnitedHealthcare, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 64642 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 64642 on AAPC
UnitedHealthcare is removing a long list of CPT codes from the applicable-code list of its Outpatient Surgical Procedures site-of-service policy for Exchange plans, and it is also removing the link to the Manipulation Under Anesthesia policy. The change takes effect December 1, 2026. The source does not state a new billing requirement for the removed codes.
Effective December 1, 2026, UMR removes more than 500 CPT codes from its Outpatient Surgical Procedures - Site of Service medical policy for commercial plans, and it drops a reference link to the Manipulation Under Anesthesia policy. For those codes, UMR's site-of-service policy no longer applies, so the practice should update its internal UMR site-of-service and prior authorization lists before that date.
Effective December 1, 2026, UnitedHealthcare removes more than 500 CPT codes from its Outpatient Surgical Procedures - Site of Service medical policy for commercial plans, and it drops a reference link to the Manipulation Under Anesthesia policy. For those codes, the site-of-service policy no longer applies under this UnitedHealthcare commercial policy, so the practice should update its internal site-of-service and prior authorization lists before that date.
Aetna considers neurosurgical procedures medically necessary for refractory spasticity only when the member has good intrinsic lower extremity motor power but is limited in ambulation by spasticity, has the functional capacity and motivation to take part in post-operative rehabilitation, and has tried and failed non-surgical medical management including baclofen or other muscle relaxants. Aetna considers selective posterior rhizotomy experimental, investigational, or unproven when the member has concomitant dystonia or rigidity, profound lower extremity weakness where the spasticity helps the member stand, progressive neurological disorders, choreoathetosis or cerebellar ataxia, severe damage to the basal ganglia, or severe fixed joint deformities or scoliosis. Acupuncture, botulinum toxin, thalamic stimulation, cryoneurolysis, dry needling, extracorporeal shock wave therapy, mirror therapy, pulsed radiofrequency, transcranial direct current stimulation and several other techniques are considered experimental, investigational, or unproven because the effectiveness of these approaches has not been established.
Aetna considers combined steroid/anesthetic injection medically necessary for the treatment of plantar fascia when conservative treatments (such as stretching exercises, over-the-counter silicone heel shoe inserts, and 2 to 3 weeks of non-steroidal anti-inflammatory drugs) have failed. Endoscopic plantar fasciotomy is considered medically necessary as an alternative to conventional open plantar fasciotomy for members with intractable plantar fasciitis or heel spur syndrome who have failed a 6-month trial of conservative therapy. Aetna considers a list of other approaches experimental, investigational or unproven for plantar fasciitis, including extracorporeal shock-wave therapy (ESWT), botulinum toxin, dry needling, Graston technique, low-level laser therapy, platelet-rich plasma and hyaluronic acid.
Botox (onabotulinumtoxinA) is the only covered botulinum toxin preparation for non-cosmetic indications under this policy. Dysport, Myobloc and Xeomin are considered not medically necessary because a formulary alternative is available. Botox may be considered medically necessary for overactive bladder, detrusor overactivity associated with a neurologic condition, chronic migraine prophylaxis, spasticity, cervical dystonia, primary axillary hyperhidrosis, blepharospasm, strabismus and spasmodic dysphonia when all criteria for the indication are met. Each indication has a 12-month length of approval and a maximum dose per 12 weeks. Revised criteria for detrusor overactivity, migraine prophylaxis and blepharospasm were approved by the Pharmacy and Therapeutics Committee on 05/26/2026.
Botox (onabotulinumtoxinA) is the only botulinum toxin the policy covers for non-cosmetic indications, and prior authorization is required. Dysport, Myobloc and Xeomin are currently considered not medically necessary because a formulary alternative is available. The policy was reviewed and approved on 05/26/2026, and that revision states that the use of samples will not be considered current or stable therapy and revises the maximum cumulative Botox dose for individuals treated for one or more indications.
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