Medicare hospital outpatient department (OPD) prior authorization
Hospital outpatient department prior authorization code list
CMS requires prior authorization for 51 procedure codes in 8 service categories when they are furnished in a hospital outpatient department, in every state. The hospital submits the request to its Medicare contractor. From CMS’s list of outpatient department services that require prior authorization (2024-08-05).
Codes by service category
| Service category (CMS) | Codes | CMS dates |
|---|---|---|
| Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair | 15820 15821 15822 15823 67900 67901 67902 67903 67904 67906 67908 | Since 2020-07-01. 67911 removed 2022-01-07. |
| Botulinum Toxin Injection | 64612 64615 J0585 J0586 J0587 J0588 | Since 2020-07-01. |
| Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue | 15830 15847 15877 | Since 2020-07-01. |
| Rhinoplasty and related services | 20912 21210 30400 30410 30420 30430 30435 30450 30460 30462 30465 30520 | Since 2020-07-01. 21235 removed 2020-06-10. |
| Vein Ablation and related services | 36473 36474 36475 36476 36478 36479 36482 36483 | Since 2020-07-01. |
| Cervical Fusion with Disc Removal | 22551 22552 | Since 2021-07-01. |
| Implanted Spinal Neurostimulators | 63650 | Since 2021-07-01. |
| Facet Joint Interventions | 64490 64491 64493 64494 64633 64634 64635 64636 | Since 2023-07-01. 64492 and 64495 removed 2024-08-05 (three- and four-level procedures are non-covered under the revised LCDs). |
How a request is decided
- Where
- every state; hospital outpatient department only
- Who submits
- the hospital, to its Medicare contractor (portal, fax or esMD)
- Decision
- 7 calendar days; 2 business days expedited
- Coverage policy
- the state contractor’s LCD for the service — the check finds it
In an ambulatory surgical center instead
This list applies in a hospital outpatient department only. 35 of these codes are also in CMS’s separate ASC prior authorization demonstration when furnished in an ambulatory surgical center in ten states.
Check a procedure for your state, diagnosis and setting
Which program applies, the governing coverage policy as it stands today, whether the diagnosis is on its list, and the documentation the policy’s own text requires. Free; nothing about the patient is entered.
Run the check →Sources: CMS list of OPD services requiring prior authorization (2024-08-05) · CMS program page · OPD Operational Guide · OPD FAQs.
These pages report what CMS publishes. They never predict whether a request will be affirmed. Codes are shown as numbers only, as CMS lists them. CPT® is a registered trademark of the American Medical Association.