Updates are provided in reverse chronological order; scroll down for earlier updates.

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.

Update 09/15/2023:

CMS is releasing updated stats on the Prior Authorization Program for Certain Hospital OPD Services. 

Please click here to see the results.  (PDF)

Update 4/11/2023:

As part of the Calendar Year 2023 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS-1772-FC), CMS added Facet Joint Interventions to the nationwide prior authorization process for hospital outpatient department (OPD) services. OPD providers can start submitting the prior authorization requests on June 15, 2023, for dates of service on or after July 1, 2023. This service category will be in addition to the existing list of services requiring prior authorization, which are blepharoplasty, botulinum toxin injection, rhinoplasty, panniculectomy, vein ablation, implanted neurostimulators, and cervical fusion with disc removal. OPD providers that are currently exempt from submitting prior authorization requests will stay exempt for all eight service categories combined, including new services.

Access the full list of OPD services that require prior authorization (PDF).

Update 4/14/2022:

CMS has updated the code descriptions for the services subject to prior authorization to align with the current HCPCS codes descriptors defined by the American Medical Association.  CMS has also updated the HCPCS codes descriptors of the Part B Associated Codes List.  The HCPCS codes themselves have not changed.

Please see the updated codes descriptors in Appendix A and B of the Operational Guide (PDF).

Access the Final List of Outpatient Department Services That Require Prior Authorization (PDF).

Update 12/28/2021:

Removal of HCPCS code
Beginning for dates of service on or after January 7, 2022, CMS is removing CPT 67911 (correction of lid retraction) from the list of codes that require prior authorization as a condition of payment. This service is not likely to be cosmetic in nature and commonly occurs secondary to another condition. The full list of HCPCS codes (PDF) has been updated to reflect this change.

Exemption Process
CMS revised the exemption process for the hospital OPD providers and extended the exemption cycle. OPD providers who are currently exempt should receive the notice of continued exemption by January 10, 2022. Exempt providers should not submit prior authorization requests. Providers who are not exempt should continue to submit prior authorization requests. More detailed information is provided in the Operational Guide and the Frequently Asked Questions in the Downloads section below.

Update 5/13/2021:

CMS is temporarily removing CPT codes 63685 and 63688 from the list of OPD services that require prior authorization. The only service that will require prior authorization for implanted spinal neurostimulators is CPT code 63650. Providers who plan to perform both the trial and permanent implantation procedures using CPT code 63650 in the OPD will only require prior authorization for the trial procedure. When the trial is rendered in a setting other than the OPD, providers will need to request prior authorization for CPT code 63650 as part of the permanent implantation procedure in the hospital OPD.

Please see additional information in the Operational Guide (PDF) and Frequently Asked Questions (PDF).

The full list of codes requiring prior authorization is available here (PDF).

Update 02/26/2021:

As part of the Calendar Year 2021 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS-1736-FC), CMS is adding Implanted Spinal Neurostimulators and Cervical Fusion with Disc Removal to the nationwide prior authorization process for hospital outpatient department (OPD) services, effective July 1, 2021. These two services will be in addition to the existing list of services requiring prior authorization, which include blepharoplasty, botulinum toxin injection, rhinoplasty, panniculectomy, and vein ablation.

Additionally, MACs are in the process of identifying those hospital OPDs that will be exempt from the prior authorization process. Starting February 1, 2021 MACs began calculating the affirmation rate of initial prior authorization requests submitted. Hospital OPD providers who met the affirmation rate threshold of 90% or greater will receive a written Notice of Exemption no later than March 1, 2021. Those hospital OPDs will be exempt from submitting prior authorization requests for dates of service beginning May 1, 2021.

HCPCS Code Update 6/15/2020:

CMS removed HCPCS code 21235 (obtaining ear cartilage for grafting) from the list of codes that require prior authorization as a condition of payment, because it is more commonly associated with procedures unrelated to rhinoplasty that are not likely to be cosmetic in nature. The full list of HCPCS codes (PDF) has been updated to reflect this change.

• OPD Operational Guide (PDF)
• OPD Frequently Asked Questions (PDF)
• List of HCPCS Codes for OPD Services Requiring Prior Authorization (PDF)
• OPD Open Door Forum Slides 05-28-2020 (PDF)