Prior Authorization for Certain Hospital 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 for dates of service July 1, 2020, and after, providers must request prior authorization for the following hospital OPD services: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation. Effective for dates of service July 1, 2021, cervical fusion with disc removal and implanted spinal neurostimulators.

The hospital OPD provider will submit the PA to their Medicare Administrative Contractor (MAC) jurisdiction. The term requestor will be used throughout this page to describe the person or entity that submits the prior authorization request (PAR), documentation, and/or claims. The MAC will review information submitted and issue the decision (affirmative or non-affirmative) to the provider.

The provider may resubmit a PAR with additional supporting information, upon receipt of a non-affirmation, as many times as necessary to achieve an affirmation decision.

For questions, please contact Be sure to include the Beneficiary's MBI, PTAN, CPT/HCPCS code(s), UTN (unique tracking number, and the issue you are experiencing.


Last Updated Apr 02 , 2024