Subscribe to eNews Contact us

Prior authorization (PA) program for certain hospital outpatient department (OPD) services: General documentation requirements

To meet coverage criteria, the patient’s medical record must contain documentation that fully supports the medical necessity for services. The general documentation requirements are listed below. Where applicable, refer to the LCDs and LCAs for these services:

  • Blepharoplasty, Eyelid Surgery, Brow Lift, and Related Services
  • Botulinum toxin injections
  • Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services
  • Rhinoplasty and related services
  • Vein ablation and related services
  • Cervical fusion with disc removal
  • Implanted spinal neurostimulators
  • Facet joint interventions

For any service or item to be covered by Medicare, it must:

  • Be eligible for a defined Medicare benefit category
  • Be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and
  • Meet all other applicable Medicare statutory and regulatory requirements

Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair

General documentation requirements

  • Documented subjective patient complaints which justify functional surgery (vision obstruction, unable to do daily tasks, etc.)
  • Documented excessive upper/ lower lid skin
  • Signed clinical notes support a decrease in peripheral vision and/or upper field vision causing the functional deficit (when applicable)
  • Signed physician’s or non-physician practitioner’s documentation of functional impairment and recommendations
  • Supporting pre-op photos (when applicable)
  • 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 (e.g., 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 (e.g., Fasanella-Servat type)

 Botulinum Toxin Injections

General documentation requirements

  • A covered diagnosis
  • Dosage and frequency of planned injections
  • Specific site(s) injected (refer to your MAC’s LCD/LCA)
  • Documentation to support the medical necessity when electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s) (when applicable)
  • To support continuous treatment, the documentation should include the clinical effectiveness of two consecutive treatments that preceded the anticipated procedure (refer to your MAC’s LCD/LCA)
  • Documentation of the management of a chronic migraine diagnosis. A medical record must include a history of migraine and experiencing frequent headaches on most days of the month
  • Documentation of traditional treatments such as medication, physical therapy, and other appropriate methods have been tried and proven unsuccessful (when applicable)

Coverage criteria

Codes

Code Description
64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (e.g., for blepharospasm, hemifacial spasm)
64615 Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (e.g., 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, excision of excess skin and subcutaneous tissue (including lipectomy), and related services 

General documentation requirements

  • Stable weight loss with BMI less than 35 be obtained prior to authorization of coverage for panniculectomy surgery (when applicable)
  • Description of the pannis and the underlying skin
  • Description of conservative treatment undertaken and its results
  • The medical record documents 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-operative photograph, if requested
  • Copies of consultations, when applicable
  • Related operative report(s), when applicable
  • Any other pertinent information

For PARs submitted for CPT 15877, providers should, if applicable, document the main procedure that will be performed on the same day as CPT 15877 in the documentation submitted with the PAR.

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 (e.g.,

abdominoplasty) (includes umbilical transposition and fascial plication)
15877 Suction assisted lipectomy; trunk

Rhinoplasty, and related services 

General documentation requirements

  • Medical documentation, with evaluation and management, supporting medical necessity of the service that is to be performed
  • Radiologic imaging if done
  • Photographs that document the nasal deformity, if applicable
  • Documentation supporting unresponsiveness to conservative medical management (if applicable)

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 (e.g., spreader grafting, lateral nasal wall reconstruction)
30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft

 Vein Ablation, and related services 

General documentation requirements

  • Doppler ultrasound
  • Documentation stating the presence or absence of DVT (deep vein thrombosis), aneurysm, and/or tortuosity (when applicable)
  • Documented Incompetence 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 documentation received, is inconclusive
  • Documentation supporting the diagnosis of symptomatic varicose veins (evaluation and complaints), and the failure of an adequate trial of conservative management (before the initial procedure) (refer to your MAC’s LCD/LCA).

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
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
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
36482 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., 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 (e.g., 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

 Cervical fusion with disc removal 

General documentation requirements

  • Persistent or recurrent moderate or severe arm pain (4 or more on the visual analog scale [VAS] or equivalent) present for a minimum of 12 weeks
  • Duration/character/location/radiation of pain
  • Activity of daily living (ADL) limitations negatively impacted by nerve compression
  • Condition requiring procedure
  • Imaging reports pertinent to performed procedure (MRI or CT):
    • Evidence of stenosis at level corresponding with clinical signs or symptoms and at least one of the below following:
      • Cervical degenerative disc disease
      • Congenital short pedicles
      • Tumors (primary or metastatic)
      • Infection or Post infection radiographic findings
      • Ossification of vertebral ligament
      • Spinal instability
      • Deformities such as kyphosis, pseudoarthrosis, spondylolisthesis, or rheumatoid arthritis instability
      • Traumatic injuries including fracturs, dislocations, ligament disruption
      • Cord compression with or without increased cord signal
  • Operative report(s) (when applicable)
  • All other potential sources of pain/neurological deficit have been excluded
  • Documented failure to respond to multimodal conservative as defined by the LCD including but are not limited to*:
    • Combination of medications such as non-steroidal anti-inflammatory (NSAIDs) serotonin and norepinephrine reuptake inhibitors (NRIs), analgesics
    • Spinal manipulation therapy
    • Physical therapy
    • Cognitive behavioral therapy (CBT)
    • Home exercise program
    • Acupuncture
    • Epidural steroid injection
    • Thermo and cryo therapies

*When imminent surgery is required, and the medical records are submitted without conservative treatment documentation, supporting documentation must be received in the form of imaging report(s), physical findings correlated to the imaging, and the surgeon’s note(s)

Codes

Code Description
22551 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
22552 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace

Coverage criteria

Implanted spinal neurostimulators 

Providers who plan to perform both the trial and permanent implantation procedures using CPT 63650 in the hospital OPD will only be required to submit a PAR for the trial procedure. To avoid a claim denial, providers must place the Unique Tracking Number (UTN) received for the trial procedure on the claim submitted for the permanent implantation procedure. When the trial is rendered in a setting other than hospital OPD, providers will need to request PA for CPT 63650 as part of the permanent implantation procedure in the hospital OPD.

General documentation requirements

  • Indicate if this request is for a trial or permanent placement
  • Physician office notes including:
    • Condition requiring procedure
    • Physical evaluation
    • Treatments tried and failed including but are not limited to:
      • Spine surgery
      • Physical therapy
      • Medications
      • Injections
      • Psychological therapy
  • Documentation of appropriate psychological evaluation:
  • For permanent placement, include all the above documentation, as well as documentation of pain relief with the temporary implanted electrode(s):
    • A successful trial should be associated with at least 50% reduction of target pain or 50% reduction of analgesic medications.
  • Services associated with devices approved under an Investigational Device Exemption (IDE) study must undergo PA and meet the coverage requirements in NCD 160.7 external.gif.

Coverage criteria

Codes

Code Description
63650 Percutaneous implantation of neurostimulator electrode array, epidural

 

Note: 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 temporarily removed from the list of OPD services that require prior authorization, as finalized in the CMS-1736-FC 

Facet joint interventions

General documentation requirements

  • Intraarticular (IA) facet joint Injections, medial branch blocks (MBB), and radiofrequency ablations (RFA)
    • Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale, and
    • Presence of pain for minimum of 3 months with documented failure to respond to conservative management, and
    • Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst), and
    • Non-facet pathology must be ruled out based on clinical evaluation or radiology studies
    • The scales used to assess the measurement of pain and/or disability must be obtained at baseline and documented in the medical record for each assessment (refer to LCD/LCA).
  • Diagnostic facet joint procedures (IA or MBB)
  • Indicate if this request is for an initial or second diagnostic procedure
  • For the first diagnostic facet joint procedure, documentation must support the criteria outlined in general documentation requirements for facet joint interventions
  • Diagnostic procedures should be performed with the intent that if successful, RFA would be considered the primary treatment goal at the diagnosed level(s)
  • For the second diagnostic facet joint procedure(s), documentation must support the following:
    • Documentation must support the requirements for the first diagnostic procedure at the same level, and
    • After the first diagnostic procedure, there must be at least 80% of pain relief, and
    • The second diagnostic procedure may only be performed a minimum of 2 weeks after the initial diagnostic procedure. Exception to the two-weeks duration may be considered on an individual basis and must be clearly documented in the medical record

Frequency limitation for IA/MBB: For each covered spinal region, no more than four (4) diagnostic joint sessions will be considered medically reasonable and necessary per rolling 12 months, in recognition that the pain generator cannot always be identified with the initial and confirmatory diagnostic procedure.

Therapeutic facet joint procedures (IA)

  • Indicate if this request is for an initial or subsequent therapeutic procedure
  • Documentation of two (2) diagnostic facet joint procedures with each providing at least 80% of pain relief, and
  • Subsequent therapeutic facet joint procedures at the same anatomic site with at least 50% pain relief for at least 3 months from the prior therapeutic procedure or at least 50% improvement in the ability to perform previously painful movements and ADLs, compared to baseline measurement using the same scale, and
  • Documentation of why the beneficiary is not a candidate for radiofrequency ablation (RFA)

Frequency limitation: For each covered spinal region no more than four (4) therapeutic facet joint injection (IA) sessions will be reimbursed per rolling 12 months.

Coverage criteria

Code Description
64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level
64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level
64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint
64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
63636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint

 

Note: The following CPT codes were removed on August 16, 2024, and no longer require prior authorization:

  • 64492 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s))
  • 64495 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s))

Three (3) or four (4) level procedures are not medically necessary and therefore are non-covered.

 

References