Skip to Main Content
 
 
 
Web Content Viewer

News and Alerts

Web Content Viewer

Prior Authorization Program Becomes Effective for Dates of Service on/after 7/1/2020

The CMS is implementing a prior authorization program for certain hospital outpatient department services effective for dates of service on or after 7/1/2020. Requests for prior authorization can be submitted beginning 6/17/2020. The list of codes currently impacted are included in this update as well as in the CMS Change Request 11671 Provider Education for Required Prior Authorization (PA) of Hospital Outpatient Department (OPD) Services.

Additional information is available on the CMS website: Prior Authorization Program for Certain Hospital Outpatient Department (OPD) Services

Final Rule: CMS-1717-FC: Prior Authorization Process and Requirements for Certain Hospital Outpatient Department (OPD) Services

Table 65: Final List of Outpatient Services that Require Prior Authorization

Federal Register/Vol. 84, No. 218/Tuesday, 11/12/2019

Code (i) Blepharoplasty, Eyelid Surgery, Brow Lift and Related Services
15820 Removal of excessive skin of lower eyelid
15821 Removal of excessive skin of lower eyelid and fat around eye
15822 Removal of excessive skin of upper eyelid
15823 Removal of excessive skin and fat of upper eyelid
67900 Repair of brow paralysis
67901 Repair of upper eyelid muscle to correct drooping or paralysis
67902 Repair of upper eyelid muscle to correct drooping or paralysis
67903 Shortening or advancement of upper eyelid muscle to correct drooping or paralysis
67904 Repair of tendon of upper eyelid
67906 Suspension of upper eyelid muscle to correct drooping or paralysis
67908 Removal of tissue, muscle, and membrane to correct eyelid drooping or paralysis
67911 Correction of widely-opened upper eyelid

 

Code (ii) Botulinum Toxin Injection
64612 Injection of chemical for destruction of nerve muscles on one side of face
64615 Injection of chemical for destruction of facial and neck nerve muscles on both sides of face
J0585 Injection, onabotulinumtoxina, 1 unit
J0586 Injection, abobotulinumtoxina
J0587 Injection, rimabotulinumtoxinb, 100 units
J0588 Injection, incobotulinumtoxin a

 

Code (iii) Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and related services
15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (list separately in addition to code for primary procedure)
15877 Suction assisted removal of fat from trunk

 

Code (iv) Rhinoplasty and related services
20912 Nasal cartilage graft
21210 Repair of nasal or cheek bone with bone graft
21235 Obtaining ear cartilage for grafting
30400 Reshaping of tip of nose
30410 Reshaping of bone, cartilage, or tip of nose
30420 Reshaping of bony cartilage dividing nasal passages
30430 Revision to reshape nose or tip of nose after previous repair
30435 Revision to reshape nasal bones after previous repair
30450 Revision to reshape nasal bones and tip of nose after previous repair
30460 Repair of congenital nasal defect to lengthen tip of nose
30462 Repair of congenital nasal defect with lengthening of tip of nose
30465 Widening of nasal passage
30520 Reshaping of nasal cartilage

 

Code (v) Vein Ablation and related services
36473 Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
36474 Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
36475 Destruction of insufficient vein of arm or leg, accessed through the skin
36476 Radiofrequency destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
36478 Laser destruction of incompetent vein of arm or leg using imaging guidance, accessed through the skin
36479 Laser destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
36482
Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance
36483
Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance

Revised 6/4/2020
Posted 5/22/2020


Last Modified: 6/4/20
Prior Authorization Program Becomes Effective for Dates of Service on/after 7/1/2020
Complementary Content