Prior Authorization for Certain Hospital Outpatient Department (OPD) Services
Background
Through the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS-1717-FC (PDF)), CMS established a nationwide prior authorization 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.
CMS believes prior authorization for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care – while protecting the Medicare Trust Fund from improper payments and, at the same time, keeping the medical necessity documentation requirements unchanged for providers.
This program was established under Section 1833(t)(2)(F) of the Social Security Act (the Act), which authorizes the Secretary to establish methods to control unnecessary increases in the volume of hospital outpatient department (OPD) services.
The following hospital OPD services will require prior authorization when provided on or after July 1, 2020:
- Blepharoplasty
- Botulinum toxin injections
- Panniculectomy
- Rhinoplasty
- Vein ablation
The following hospital OPD services will require prior authorization when provided on or after July 1, 2021:
- Implanted Spinal Neurostimulators
- Cervical Fusion with Disc Removal
The following hospital OPD services will require prior authorization when provided on or after July 1, 2023:
- Facet Joint Interventions
Download the full list of HCPCS codes requiring prior authorization (PDF).
Contact Us
RCD providers can email questions to OPDPA@cms.hhs.gov.
For Mac contact information, please see page 7 of the OPD Operational Guide. This can be found in the Downloads section.
Timeline & Updates
Updates are provided in reverse chronological order; scroll down for earlier updates.
Update 09/16/2025:
CMS is releasing updated stats on the Prior Authorization Program for Certain Hospital OPD Services. Please click here to see the results (PDF).
Update 11/14/2024:
CMS is changing the review timeframe for standard prior authorization decisions from 10 business days to 7 calendar days for requests submitted on or after January 1, 2025. The timeframe for expedited requests remains 2 business days.
Update 08/05/2024:
CPT Codes Update
CMS is removing CPTs 64492 and 64495 from the list of codes that require prior authorization as a condition of payment. According to the revised Local Coverage Determinations for Facet Joint Interventions, three or four-level procedures are not medically necessary and non-covered. Therefore, the decision on the prior authorization request will always be non-affirmative, so submitting the request would be unnecessary. The full list of HCPCS codes (PDF) has been updated to reflect this change.