Outpatient Department Prior Authorization (PA)
The Centers for Medicare & Medicaid Services (CMS) has established a nationwide prior authorization (PA) 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 and to ensure that medical necessity is met.
- Botulinum toxin injections
- Vein ablation
Providers can submit a PA request for dates of service on or after July 1, 2021, for the following:
- Cervical Fusion with Disc Removal
- Implanted Spinal Neurostimulators
For dates of service on or after July 1, 2023, prior authorization must be requested for the hospital OPD claim for Facet Joint Interventions. The list of procedure codes for Facet Joint Interventions can be found in Change Request 13016 (PDF).
Please watch our website for upcoming education regarding OPD PA. You may go to the CMS website to view a full list of HCPCS codes that require a PA.