June 17, 2020

CMS Offers Details About Prior Authorization for Specific Procedures

The Centers for Medicare and Medicaid Services (CMS) released informational materials last week to assist providers with prior authorization requirements for certain hospital outpatient procedures. The new rules take effect July 1, 2020.

CMS states its prior authorization policy will ensure that all applicable Medicare coverage, payment and coding requirements are met before a service is provided. The following hospital outpatient department services will require prior authorization when provided on or after July 1:

  • Blepharoplasty
  • Botulinum toxin injections
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation

CMS targeted procedures that possibly involve cosmetic surgery or are directly related to cosmetic surgical procedures that are not covered by Medicare but may be combined with therapeutic services.

Medicare Administrative Contractors began accepting prior authorization requests on June 17. CMS has provided a full list of applicable HCPCS codes.

American College of Radiology® staff will monitor the possible expansion of these policies into procedural categories that could relate to interventional and diagnostic radiology.