Five Medicare Administrative Contractors (MAC) recently implemented new policies for the provision of botulinum toxin injections for services performed on or after February 22, 2026. The new local coverage determinations (LCD) from CGS, NGS, Noridian, WPS, and Palmetto GBA include dosing guidelines and new documentation requirements, including the administration of an objective assessment to measure illness severity at baseline, after each diagnostic procedure, and at each follow-up assessment for the treatment of conditions such as migraine, dystonia, blepharospasm, and sialorrhea, among others.
MACs may create LCDs that apply to their geographic jurisdictions to explain when a service or procedure is considered reasonable and medically necessary. LCDs outline coverage criteria, medical necessity standards, and coding and billing rules. Â鶹´«Ã½Ó³» members should verify coverage requirements for their individual MAC and other commercial payers, as policies may vary.
Practices that administer botulinum toxin injections and contract with these MACs should be aware of greater off-label justification requirements, allowed baseline and subsequent dosing, and whether documentation practices correspond to the indications of coverage for each condition.
Additionally, many providers may not routinely administer objective clinical scales for each of the conditions outlined in the policy. The LCD suggests a series of scales for each diagnosis, but practices should consider options that work best for their clinical workflows.
The current policies and related coding articles for each MAC are included below. Questions? Email practice@aan.com.
A Contractor Advisory Committee (CAC) serves as a vital component in the development of Local Coverage Determinations (LCDs) by providing expert input on clinical evidence and medical practices. Below is an overview and frequently asked questions to help stakeholders understand the CAC's role and operations.
What is a CAC?
A Contractor Advisory Committee (CAC) is a federally mandated regional committee convened by Medicare Administrative Contractors (MACs) to consult with healthcare professionals and subject matter experts on clinical evidence and literature. A CAC provides input on regional policies, known as Local Coverage Determinations (LCDs), which determine whether specific medical services or items are covered by Medicare within a given jurisdiction.
Although Medicare is a federal program, much of the policy setting, payment processing, and utilization review is managed at the regional level by MACs. These contractors—often divisions of large health insurance companies—oversee defined geographic jurisdictions and employ medical directors and administrative staff.
CACs are advisory in nature. The final decision on LCDs rests with the Contractor Medical Director (CMD). Historically, CMDs have been highly responsive to the suggestions from CACs.
Who makes up a CAC?
A CAC is composed of the MAC medical director and physicians from each medical specialty group, as well as representatives from medical societies, beneficiary representatives, and representatives of medical organizations. The minimum composition of a CAC is mandated by CMS and includes one physician representative from each of the major medical specialties and a designated alternate approved by the MAC. Physician representatives are nominated by their specialty societies. The length of service is specified by the MAC or by the nominating specialty.
What are the duties of a CAC representative?
Serving in an advisory capacity to review the quality of evidence used in the development of an LCD.
Providing a formal mechanism for health care professionals to be informed of the evidence used in developing the LCD.
Promoting communication between the MAC and the healthcare community.
How can I influence coverage decisions on a CAC?
While CACs do not make final coverage decisions, their expert input significantly informs the development of LCDs. Contractor Medical Directors (CMDs) consider the CAC's recommendations alongside other evidence when making final decisions on coverage. This collaborative process ensures that Medicare coverage policies are based on current and comprehensive medical evidence.
How are meetings conducted?
CAC meetings are scheduled as needed to discuss specific topics. These meetings are open to the public, with non-CAC members typically participating in a listen-only mode via teleconference or webinar. Discussions focus on reviewing clinical literature and evidence related to proposed LCDs. The final decision on coverage determinations rests with the CMDs, who consider the CAC's recommendations.
What is the time commitment for a CAC?
The time commitment is minimal, based on the number of meetings each year. If you cannot attend, an approved alternate may attend in your place.
How do I apply to join a CAC?
Members are typically nominated based on their expertise and experience in relevant medical fields. Participation is voluntary, and members do not receive compensation. To participate, members must submit completed and signed Conflict of Interest (COI) and Consent to Disclose and Publish Expert Opinion forms. Failure to submit these forms may result in non-compliance, affecting participation eligibility.
Please email practice@aan.com, indicating in the subject line that you are applying for your local CAC. Please include your CV and any Â鶹´«Ã½Ó³» references. Once we receive your request, we will review your application and seek approval from Â鶹´«Ã½Ó³» leadership. If approval is granted, we will submit a letter of recommendation to be submitted with your application to the Medicare Administrative Contractor.
Though you may apply with your local MAC to be considered and have a recommendation from the Â鶹´«Ã½Ó³», the ultimate decision is up to the MAC.
How do I find out more information or contact the CAC?
For more information or to contact the CAC, visit the For example, Noridian provides contact details and resources related to their CAC on their website.
You can also review additional details in the
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