Prior Authorization Details

The Exemption Process: Additional Documentation Request

Suggested list of documentation for all services to submit to National Government Services

Note: Please remember, this is not an all-inclusive list

Blepharoplasty, Eyelid Surgery, Brow Lift and Related Services: Reason Code 58BPP

  • History and physical; include subjective patient complaints commonly found in association with the presenting condition which justify functional surgery, documented excessive upper/lower lid skin, clinical notes that support a decrease in peripheral vision and/or upper field vision.
  • Support for the medical necessity of procedures performed; include diagnosis code(s) that best describe the condition for which the service was performed.
  • Signed physician’s or non-physician practitioner recommendations.
  • An operative note or procedure note for the service. This note should describe the anatomical location treated and include a description of the procedure performed.
  • Visual field studies/exams (when applicable).
  • Pre-op photographs (when applicable).
  • Documentation to support the use of modifiers, if any used.
  • If an ABN was issued, please include a copy of the signed and dated ABN of non-coverage to the beneficiary.

Botulinum Toxin Injections: Reason Code 58BTP

  • History and physical including: diagnosis (es), statement that traditional methods of treatments such as medication, physical therapy, and other appropriate methods have been tried and proven unsuccessful (when applicable), support for the clinical effectiveness of the injections for continuous treatment.
  • Support for the medical necessity of the botulinum toxin (type A or type B) injection.
  • Support for the medical necessity of electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site (s) (when applicable).
  • Physician’s orders for all services billed (if applicable); include dose, frequency, and injection sites of planned injections.
  • Medication administration records; include specific units given, documentation of any drug waste, personnel who administered the medication.
  • An operative note or procedure note for the administration of Botulinum. This note should describe the injection sites, dose, and electromyography if required.
  • For support of management of a chronic migraine diagnosis, the medical record must include a history of migraine and experiencing frequent headaches on most days of the month.
  • Documentation to support the use of modifiers, if any used.
  • If an ABN was issued, please include a copy of the signed and dated ABN of non-coverage to the beneficiary.

Cervical Fusion with Disc Removal: Reason Code 58CVP

  • History and physical that includes the following: condition requiring the procedure; duration/character/location/radiation of pain; ADL limitations; conservative treatments tried (PT, OT, injections, medications, assistive devices, activity modification).
  • Operative note describing the procedure performed.
  • Any pertinent imaging reports.
  • Previous operative reports (when applicable).
  • Documentation to support the use of modifiers, if any used.
  • If an ABN was issued, please include a copy of the signed and dated ABN of non-coverage to the beneficiary.

Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy), and Related Services: Reason Code 58PNP

  • History and physical including: stable weight loss with BMI less than 35 be obtained prior to authorization of coverage for panniculectomy surgery (when applicable); description of the pannus and the underlying skin; description of conservative treatment undertaken and its results; indication that the panniculus causes chronic intertrigo or candidiasis or tissue necrosis that consistently recurs over three months and is unresponsive to oral or topical medication (when applicable).
  • Documentation that supports complicating factors were present for at least three months and were refractory to standard medical therapy (inability to walk, chronic pain, ulceration, intertrigal dermatitis); surgical incision that may be subject to improper healing if a panniculectomy is not performed at the same time as the primary procedure.
  • Operative note that describes the procedure performed.
  • Pre-op photographs.
  • Copies of consultations (when applicable).
  • Related operative report(s) (when applicable).
  • Any other pertinent information.
  • Documentation to support the use of modifiers, if any used.
  • If an ABN was issued, please include a copy of the signed and dated ABN of non-coverage to the beneficiary.
  • Rhinoplasty, and related services: Reason Code 58RHP
  • History and physical including: evaluation and management, supporting medical necessity of the service that is to be performed.
  • Documentation supporting unresponsiveness to conservative medical management in the presence of obstructions or deviation. (if applicable).
  • An operative or procedure note describing the following: the anatomical location treated, the procedure performed.
  • Pertinent radiology report(s).
  • Photographs in the presence of an acquired or congenital deformity (if applicable).
  • Documentation to support the use of modifiers, if any used.
  • If an ABN was issued, please include a copy of the signed and dated ABN of non-coverage to the beneficiary.

Implanted Spinal Neurostimulators: Reason Code 58SNP

  • History and physical that includes the following: condition requiring the procedure; treatments tried and failed or contraindicated; distinction between a trial and permanent system.
  • Psychological evaluation.
  • An operative note for the service billed. This note should describe the procedure performed, the location and number of the leads placed, and whether this is trial or permanent placement.
  • Permanent placements must include documentation of the trial. A successful trial should be associated with at least a 50% reduction in pain or analgesic medications.
  • Any pertinent radiology and laboratory reports, if applicable.
  • Documentation to support the use of modifiers, if any used.
  • If an ABN was issued, please include a copy of the signed and dated ABN of non-coverage to the beneficiary.

Vein Ablation and Related Services: Reason Code 58VEP

  • Relevant medical history and physical examination including the following: findings that support a diagnosis of symptomatic varicose veins (evaluation and complaints); failure of an adequate trial of conservative treatment (at least three months prior to the initial procedure), exclusion of other causes of edema, ulceration and pain in the limbs; documentation of incompetence of the valves of the saphenous, perforator or deep venous systems consistent with the patient’s symptoms and findings (when applicable); signs and symptoms associated with the diseased vessels.
  • Results of pertinent diagnostic tests or procedures that confirm the presence and location of incompetent perforating veins; location and the number of varicosities, level of incompetence and veins involved, presence or absence of DVT, aneurysm, and/or tortuosity (when applicable).
  • Pre-treatment photographs (when applicable).
  • Any pertinent radiology and laboratory reports. (if applicable).
  • Operative or procedure note that describes the procedure performed, instruments used, veins treated, and necessity of utilizing ultrasound guidance to support billing.
  • Documentation to support the use of modifiers, if any used.
  • If an ABN was issued, please include a copy of the signed and dated ABN of non-coverage to the beneficiary.

Facet Joint Interventions: Reason Code 58FCP

  • The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit.
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report.

Medical necessity criteria for each intervention type

  • Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale.
    • Pain assessment or disability scale must be performed and documented at baseline and after each procedure using the same scale for each assessment.
  • Pain present for minimum of three months with documented failure to respond to noninvasive conservative management (as tolerated)
  • Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst).
  • There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient’s pain, including but not limited to fracture, tumor, infection, or significant deformity.

Diagnostic injections

  • Indicate if this request is for an initial or second diagnostic procedure.
  • Diagnostic procedures should be performed with the intent that if successful, RFA would be considered the primary treatment goal at the diagnosed level(s)
    • For the second diagnostic facet joint procedure(s), documentation must support the following: Documentation requirements for the first diagnostic procedure at the same level, and
    • After the first diagnostic procedure, there must be at least 80% consistent pain relief, and
    • The second diagnostic procedure may only be performed a minimum of two weeks after the initial diagnostic procedure.

*Frequency limitation for IA/MBB: For each covered spinal region, no more than four diagnostic joint sessions will be considered medically reasonable and necessary per rolling 12 months, in recognition that the pain generator cannot always be identified with the initial and confirmatory diagnostic procedure.

Therapeutic injections

  • Indicate if this request is for an initial or subsequent therapeutic procedure.
  • Documentation of two diagnostic facet joint procedures with each providing at least 80% consistent pain relief.
  • Subsequent therapeutic facet joint procedures at the same anatomic site with at least 50% consistent pain relief for at least three months from the prior therapeutic procedure or at least 50% improvement in the ability to perform previously painful movements and ADLs, compared to baseline measurement using the same scale.
  • Documentation of why the beneficiary is not a candidate for RFA.

*Frequency limitation: For each covered spinal region no more than four therapeutic facet joint injection (IA) sessions will be reimbursed per rolling 12 months.

Radiofrequency Ablation

  • Indicate if this request is for an initial or subsequent facet joint denervation procedure.
  • For the initial thermal RFA: documentation must support at least two diagnostic procedures with each one providing at least 80% consistent pain relief.
  • Subsequent thermal facet joint RFA at the same anatomic site with at least 50% consistent pain improvement for at least six months or at least 50% improvement in the ability to perform previously painful movements and ADLs, compared to baseline measurement using the same scale.

*Frequency limitation: For each covered spinal region no more than two radiofrequency sessions will be reimbursed per rolling 12 months.

Facet Cyst Aspiration/Rupture

Intra-articular facet joint injection performed with synovial cyst aspiration is considered medically necessary when both of the following criteria are met:

  • Advanced diagnostic imaging study (e.g., MRI/CT/myelogram) confirm compression or displacement of the corresponding nerve root by a facet joint synovial cyst; and
  • Clinical and physical symptoms related to synovial facet cyst are documented.

*Frequency Limitation: Cyst aspiration/rupture may be repeated once and only if there is 50% or more consistent improvement in pain for at least three months.

Revised 6/21/2024