Prior Authorization

General Documentation Requirements for Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair

  • Documented subjective patient complaints which justify functional surgery (vision obstruction, unable to do daily tasks, etc.
  • Documented excessive upper/lower lid skin;
  • Signed clinical notes support a decrease in peripheral vision and/or upper field vision causing the functional deficit (when applicable);
  • Signed physician’s or non-physician practitioner’s documentation of functional impairment and recommendations;

  • Supporting pre-op photos (when applicable);

  • Visual field studies/exams (when applicable).

This checklist is not all inclusive; please submit any additional medical records that help support the medical necessity of the Hospital Outpatient Department service.

A facility or the beneficiary may submit the PAR and supplemental documentation via NGSConnex, esMD, fax or mail.

  • NGSConnex
  • esMD: Content type 8.5
  • Fax
    JK: 317-841-4530
    J6: 317-841-4528
  • Mail
    National Government Services, Inc.
    Attention: Medical Review Prior Authorization Request
    P.O. Box 7108
    Indianapolis, IN 46207-7108

Provider Contact Center Inquiry Line:

  • JK: 888-855-4356
  • J6: 877-702-0990

Related Content:

PAR decisions and the unique tracking numbers assigned for these services will be valid for 120 days. The decision date shall be counted as the first day of the 120 days. For example: if the PAR is affirmed on 1/1/2021, the PAR will be valid for dates of service through 4/30/2021. Otherwise, the provider will need to submit a new PAR.