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Title 42

Displaying title 42, up to date as of 9/14/2021. Title 42 was last amended 8/16/2021.

Title 42

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§ 419.83 List of hospital outpatient department services requiring prior authorization.

(a) Service categories for the list of hospital outpatient department services requiring prior authorization.

(1) The following service categories comprise the list of hospital outpatient department services requiring prior authorization beginning for service dates on or after July 1, 2020:

(i) Blepharoplasty.

(ii) Botulinum toxin injections.

(iii) Panniculectomy.

(iv) Rhinoplasty.

(v) Vein ablation.

(2) The following service categories comprise the list of hospital outpatient department services requiring prior authorization beginning for service dates on or after July 1, 2021:

(i) Cervical Fusion with Disc Removal.

(ii) Implanted Spinal Neurostimulators.

(3) Technical updates to the list of services, such as changes to the name of the service or CPT code, will be published on the CMS website.

(b) Adoption of the list of services. CMS will adopt the list of hospital outpatient department service categories requiring prior authorization and any updates or geographic restrictions through formal notice-and-comment rulemaking.

(c) Exemptions. CMS may elect to exempt a provider from the prior authorization process in § 419.82 upon a provider's demonstration of compliance with Medicare coverage, coding, and payment rules in chapter IV of this title or in Title XVIII of the Social Security Act through such prior authorization process.

(1) An exemption will remain in effect until CMS elects to withdraw the exemption.

(2) Notice of an exemption or withdraw of an exemption will be provided at least 60 days prior to the effective date.

(d) Suspension of prior authorization process or services. CMS may suspend the outpatient department services prior authorization process requirements generally or for a particular service(s) at any time by issuing notification on the CMS website.

[84 FR 61491, Nov. 12, 2019, as amended at 85 FR 86303, Dec. 29, 2020]