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 |
| 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 6/18/2020
Posted 5/22/2020