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Prior Authorization for Certain Outpatient Department (OPD) Services

The Federal Register established a prior authorization (PA) process as a condition of payment for certain cover hospital Outpatient Department Services (OPD). Effective July 1, 2020, as the date of service, providers must request prior authorization for the following hospital OPD services: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation.

As guidance is received closer to the July implementation date, we will update this resource and provide additional clarity through education.

Authorization Process

As guidance is received closer to the July implementation date, we will update this resource and provide additional clarity through education.

Submitting a Prior Authorization Request

As guidance is received closer to the July implementation date, we will update this resource and provide additional clarity through education.

Blepharoplasty

General Documentation Requirements

  • Documented excessive upper/lower lid skin;
  • Supporting pre-op photos;
  • Signed clinical notes support a decrease in peripheral vision and/or upper field vision;
  • Documented subjective patient complaints which justify functional surgery (vision, ptosis, etc.);
  • Visual field studies/exams (when applicable).

Coverage Criteria

Codes

Code Description
15820 Blepharoplasty, lower eyelid
15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad
15822 Blepharoplasty, upper eyelid
15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)  
67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)
67902 Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach
67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach
67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)
67908 Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type)
67911 Correction of lid retraction

 

Botulinum Toxin Injections

General Documentation Requirements:

  • Support of medical necessity of the botulinum toxin (type A or type B) injection;
  • A covered diagnosis;
  • Dosage and frequency of the injections;
  • Support for medical necessity of electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s) (when applicable);
  • Support of clinical effectiveness of the injections (for continuous treatment);
  • Specific site(s) injected;
  • For support of management of a chronic migraine diagnosis, the Medical Record must include a history of migraine and experiencing headaches on most days of the month;
  • A statement that traditional methods of treatments such as medication, physical therapy, and other appropriate methods have been tried and proven unsuccessful (except for focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's camp, laryngeal spasm, or dysphonia);
  • The documentation in the medical records must show the precise amount of the drug administered and the amount discarded.

Coverage Criteria

Codes

Code Description
64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm)  
64615 Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine)
J0585 Injection, onabotulinumtoxina, 1 unit
J0586 Injection, abobotulinumtoxina, 5 units
J0587 Injection, rimabotulinumtoxinb, 100 units
J0588 Injection, incobotulinumtoxin a, 1 unit

 

Panniculectomy

General Documentation Requirements:

  • Stable weight loss with BMI less than 35 be obtained prior to authorization of coverage for panniculectomy surgery;
  • Description of the pannis and the underlying skin;
  • Description of conservative treatment undertaken and its results;
  • The medical records document(s) 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);
  • Pre-op photograph;
  • Copies of consultations;
  • Operative report (when applicable);
  • Any other pertinent information.

Coverage Criteria

Codes

Code Description
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 lipectomy; trunk

 

Rhinoplasty

General Documentation Requirements:

  • Physician office notes, including evaluation and management notes for the date of service and the note for the day the decision to perform surgery was made;
  • Radiologic imaging if done;
  • Photographs that document the nasal deformity.

Coverage Criteria

Codes

Code Description
20912 Cartilage graft; nasal septum
21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
30420 Rhinoplasty, primary; including major septal repair  
30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work)  
30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only
30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies
30465 Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction)  
30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft

 

Vein Ablation

General Documentation Requirements:

  • Doppler ultrasound;
  • Documentation stating the presence or absence of DVT (deep vein thrombosis), aneurysm, and/or tortuosity (when applicable);
  • Documented Incompetence (reflux greater than 500msec) of the valves of the Saphenous, Perforator or Deep venous systems consistent with the patient's symptoms and findings (when applicable);
  • Photographs if the clinical received is inconclusive;
  • The patient's medical record must contain a history and physical examination supporting the diagnosis of symptomatic varicose veins (evaluation and complains), and the failure of an adequate (at least 3 months) trial of conservative management (before the initial procedure).

Coverage Criteria

Codes

Code Description
36473 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated
36474 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)   
36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
36476 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)   
36478 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated
36479 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
36482 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated
36483 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

 

Advance Beneficiary Notice of Noncoverage (ABN)

Please review information on the Noridian Advance Beneficiary Notice Of Noncoverage (ABN) webpage. The table below describes modifiers used for billing services in certain situations.

Modifiers

Modifier Description
GA Modifier Waiver of liability statement issues, as required by payer policy. Advanced Beneficiary Notice (ABN) of liability required. Modifier is used to signify a line item is linked to the mandatory use of an ABN when charged both related to and not related to an ABN must be submitted on the claim. Line item must be submitted as covered, and Medicare will make the determination for payment.
GZ Modifier Item or service expected to be denied as not reasonable and necessary. Cannot be used when ABN is given. Lines submitted as non-covered will be denied as provider-liable.
GY Modifier Item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Lines submitted as non-covered and will be Patient Responsibility (PR).

 

Cosmetic Services

Please refer to the following regarding cosmetic services:

 

Resources

 

Last Updated May 12, 2020