Through the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule, CMS established a nationwide prior authorization process and requirements for certain hospital outpatient department (OPD) services. This process serves as a method for controlling unnecessary increases in the volume of these services.

Prior authorization for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care – while protecting the Medicare Trust Fund from improper payments and, at the same time, keeping the medical necessity documentation requirements unchanged for providers.

The following hospital OPD services will require prior authorization when provided on or after July 1, 2020:
Blepharoplasty
Botulinum toxin injections
Panniculectomy
Rhinoplasty
Vein ablation

The following hospital OPD services will require prior authorization when provided on or after July 1, 2021:
Implanted Spinal Neurostimulators
Cervical Fusion with Disc Removal

2021 Final full List of Outpatient Department Services That Require Prior Authorization

The following service categories comprise the list of hospital outpatient department services requiring prior authorization beginning for service dates on or after July 1, 2020:
(i) Blepharoplasty
(ii) Botulinum toxin injections
(iii) Panniculectomy
(iv) Rhinoplasty
(v) Vein ablation

i) Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair
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 ptosis
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, internal approach
67904 – Repair of tendon of upper eyelid, external approach
67906 – Suspension of upper eyelid muscle to correct drooping or paralysis
67908 – Removal of tissue, muscle, and membrane to correct eyelid drooping or paralysis

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

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 (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (list separately in
addition to code for primary procedure)
15877 – Suction assisted removal of fat from trunk

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

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

The following service categories comprise the list of hospital outpatient department services requiring prior authorization beginning for service dates on or after July 1, 2021:
(i) Cervical Fusion with Disc Removal.
(ii) Implanted Spinal Neurostimulators.

(i) Cervical Fusion with Disc Removal
22551 – Fusion of spine bones with removal of disc at upper spinal column, anterior approach, complex, initial
22552 – Fusion of spine bones with removal of disc in upper spinal column below second vertebra of neck , anterior approach, each additional interspace

(ii) Implanted Spinal Neurostimulators
63650 – Implantation of spinal neurostimulator electrodes, accessed through the skin

Note:
CPT 21235 (Obtaining ear cartilage for grafting) was removed on June 10, 2020.
CPT 67911 (Correction of lid retraction) was removed on January 7, 2022.
CPT codes 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver) and 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver) were e temporarily removed from the list of OPD services that require prior authorization, as finalized in the CMS-1736-FC.

For more information, visit: https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services