The PA program is applicable to HOPDs billing on a 13x type of bill in all US states and territories.

Effective June 17, 2020, for dates of service on or after July 1, 2020, CMS established a Prior Authorization (PA) program for the following services performed in a Hospital Outpatient Department (HOPD):

• Blepharoplasty
• Botulinum Toxin Injections
• Panniculectomy
• Rhinoplasty
• Vein Ablation

Effective June 17, 2021, for dates of service on or after July 1, 2021, CMS expanded the HOPD PA program to include two additional services:

• Cervical Fusion with Disc Removal
• Implanted Spinal Neurostimulators (Spinal Cord Stimulators)

Effective June 15, 2023, for dates of service on or after July 1, 2023, CMS expanded the HOPD PA program to include one additional service:

• Facet Joint Interventions

Before providing any of the services listed above, HOPDs must submit a PA request to their MAC.

Hospital Outpatient Departments that demonstrate compliance with Medicare coverage, coding, and payment rules related to prior authorization are eligible for exemption. Learn more.

Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair

Current Procedural Terminology (CPT) codes

Providers should include the following documentation with their blepharoplasty PA request:

• Patient complaints (difficulty reading, looking through eyelashes etc.)
• Pre-operative examination
• History and physical
• Visual fields with physician written interpretation
• Photographs (must include patient identifiers)
• Prior authorization requests should clearly identify which eye the request is for
• Any additional documentation indicating medical necessity of the planned procedure 

See our Local Coverage Determination L34528 - Blepharoplasty, Blepharoptosis and Brow Lift for coverage criteria.

See the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 , Section 120, for more information.

Botulinum Toxin Injection 

Note: The provider should pair the injection code and the pharmaceutical code appropriately. Prior authorization requests are only for injection CPT codes 64612 and 64615.

Current Procedural Terminology (CPT) codes

Providers should include the following documentation with their botulinum toxin injections PA request:

• Documentation to support a covered diagnosis
• History and physical
• Planned dosage and frequency of the injection
• Prior authorization requests must include both the administration site and drug CPT codes
• Units of service for botulinum toxin injections should include the expected units of waste
• Physician progress notes supporting the results of the last two prior injections
• Prior procedure reports supporting 12 weeks between injections
• Documentation to support the patient has been unresponsive to conventional methods of treatments
• Documentation to support a history of migraines with occurrence most days of the month, if applicable
• Any additional documentation indicating medical necessity of the planned injection

See our LCD L34635 – Botulinum Toxin Type A & Type B for coverage criteria.

See the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 , Section 120, for more information.

Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy), and Related Services

Current Procedural Terminology (CPT) codes

Providers should include the following documentation with their panniculectomy PA request:

• Progress notes supporting the decision to perform surgery
• History and physical
• Evidence of weight loss maintained for a minimum of 6 months, if applicable
• Evidence of chronic intertrigo (dermatitis, skin irritation, infection, chafing etc.) that remains refractory to medical treatments (dressing changes, topical antibiotics, oral antibiotics, corticosteroids, antifungals etc.) over a period of 3 months
• Any additional documentation indicating medical necessity of performing the surgery

See our LCD L39051 – Cosmetic and Reconstructive Services for coverage criteria.

See the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 , Section 120, for more information.

Rhinoplasty, and Related Services

Current Procedural Terminology (CPT) codes

Providers should include the following documentation with their rhinoplasty PA request:

• Progress notes supporting the decision to perform surgery
• Documentation to support a nasal obstruction
• Documentation to support deficits / structural deformities produced by trauma or nasal cutaneous disease
• Documentation to support the rhinoplasty was to replace nasal tissue lost after tumor ablative surgery
• Any additional documentation indicating medical necessity of performing the surgery

Additional information about prior authorization requests for rhinoplasty can be found in Prior Authorization for Rhinoplasty and Septoplasty.

See our LCD L39051 – Cosmetic and Reconstructive Services for coverage criteria.

See the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 , Section 120, for more information.

Vein Ablation, and Related Services

Current Procedural Terminology (CPT) codes

Providers should include the following documentation with their vein ablation PA request:

• History and physical examination supporting the diagnosis of symptomatic varicose veins and the failure of an adequate (at least 3 months) trial of conservative management
• Diagnostic test results, if medically necessary, to confirm the pathology of the vascular anatomy
• Documentation detailing the reason for each vein treatment
• Documentation of reflux and vein diameter
• Prior procedure reports including date and treatment location
• Prior authorization requests should clearly identify which extremity and vein(s) the request is for
• Any addition documentation indicating the medical necessity of the planned procedure

Additional information regarding PA requests for Vein Ablation and Related Services can be found in Prior Authorization for Vein Ablation and Related Services in a Hospital Outpatient Department.

See our LCD L34536 – Treatment of Varicose Veins for coverage criteria.

See the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 , Section 120, for more information.

Cervical Fusion with Disc Removal

Current Procedural Terminology (CPT) codes

Providers should include the following documentation with their cervical fusion with disc removal PA request:

• Condition requiring procedure
• Physical examination
• Duration/character/location/radiation of pain
• Activity of daily living (ADL) limitations
• Imaging reports pertinent to performed procedure
• Operative report(s), when applicable
• Conservative treatment modalities that include but are not limited to:
  • Physical therapy
  • Occupational therapy
  • Injections
  • Medications
  • Assistive device use
  • Activity modification

Additional information regarding PA requests for cervical fusion with disc removal can be found in Prior Authorization for Cervical Fusion with Disc Removal Performed in a Hospital Outpatient Department.

Implanted Spinal Neurostimulators (Spinal Cord Stimulators)

Current Procedural Terminology (CPT) codes

Providers should include the following documentation with their Implanted Spinal Neurostimulators PA request:

Implanted Spinal Neurostimulators (Spinal Cord Stimulators) trial or permanent

• Indication if the request is for a trial or permanent placement
• Condition requiring procedure
• Physical examination
• Treatment tried and failed including but not limited to:
  • Spine surgery
  • Physical therapy
  • Medications
  • Injections
  • Psychological therapy
• Documentation of appropriate psychological evaluation

Implanted Spinal Neurostimulators (Spinal Cord Stimulators) permanent

• Include all of the above documentation, as well as documentation of pain relief with the temporary implanted electrode(s)
  • A successful trial should be associated with at least 50% reduction of target pain or 50% reduction of analgesic medications

Additional information regarding PA requests for Implanted Spinal Neurostimulators can be found in Prior Authorization of Implantation of Spinal Neurostimulators.

See the CMS Internet-Only Manual (IOM) Publication 100-03, Medicare National Coverage Determination, Chapter 1, Part 2  Coverage Determinations, Section 160.7 – Electrical Nerve Stimulators, for more information.

Facet Joint Interventions

Current Procedural Terminology (CPT) codes

Providers should include the following documentation with their Facet Joint Interventions PA request:

• History and physical 
• Physician orders and progress notes 
• Diagnostic test results 
• Procedure records 
• Pain history to include location, severity, and duration 
• Evidence of failed conservative management 
• Disability scale rating for each new episode of pain
• Patient response to prior facet joint interventions, if applicable
• Medical history records
• Signature attestation form, if applicable 

See our LCD L38841 – Facet Joint Interventions for Pain Management for more information.

Prior Authorization Request and Documentation Submission

We encourage providers to use the WPS Government Health Administrators Portal or esMD to submit documentation. However, providers may submit their documentation via postal mail, encrypted CD/DVD/flash drive, or secure fax. All CD/DVDs/flash drives must be password protected. Please email the password and the tracking number (if applicable) to MR.ADR.Passwords@wpsic.com.

To be valid the prior authorization request must:

• Include the facility PTAN and NPI
• Include the correct Medicare Beneficiary Identifier (MBI)
• Include medical documentation for review
• Include an applicable CPT or HCPCS code
• Be legible

To help expedite the review process, complete the Hospital Outpatient Department (OPD) Prior Authorization (PA) Request Form and place it on top of your medical record documentation. 

Mail or fax your request and documentation to the appropriate address or fax number below:

Prior Authorization Request Review Process

Upon receipt of a PA request, the MAC has 10 business days to review and issue a decision (affirmed or non-affirmed). The MAC will send a detailed letter to the requester with the decision. The letter will include a Unique Tracking Number (UTN) that the Part A HOPD provider must submit on the claim. The claims processing system will reject claims submitted without a UTN even if an affirmed decision is on file. Part B physicians do not need to include it on their claims.

Providers may submit expedited requests if the standard timeframe for making a decision could seriously jeopardize the life or health of the beneficiary. We will screen expedited requests upon receipt. A Nurse Analyst will make a decision on the validity of the expedited request. If the expedited request is valid, a Nurse Analyst will issue a decision within 2 business days. If the expedited request is invalid, we will convert the request to a standard request. 

If the decision is non-affirmed the provider may resubmit the PA request. Resubmission requests should include the prior UTN and documentation to correct the non-affirmed decision.

The UTN issued is valid for one-time use for 120 days from the date of the prior authorization decision. A new UTN is not required if the anticipated date of service changes as long as it is within 120 days.

Prior Authorization for Services Performed In The Emergency Room

In the event that the place of service for a procedure requiring a PA is the HOPD emergency room WPS will issue a retroactive decision. The HOPD should submit a PA request to the MAC within two business days. The HOPD should mark the PA request as expedited with a reason of emergency room place of service. WPS will review the PA request and issue a decision within two business days.

Prior Authorization Program General Resources

• 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) Final Rule (CMS-1717-FC)
• 2021 Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) Final Rule (CMS-1736-FC)
• Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational Guide 
• Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked Questions