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 as early as June 17, 2021, for date of service on or after July 1, 2021, for the following:
- Cervical Fusion with Disc Removal
- Implanted Spinal Neurostimulators
Providers can submit a PA request as early as June 15, 2023, for date of service on or after July 1, 2023, for the following:
- Facet Joint Interventions
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.
Resource: Jurisdiction J Part A Outpatient Prior Authorization Request Form (PDF).