To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services. The general documentation requirements are listed below. Where applicable, refer to the LCDs /local coverage articles (LCAs) for these services.
Blepharoplasty, eyelid surgery, brow lift, and related services
Botulinum toxin injections
Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services
Rhinoplasty and related services
Vein ablation and related services
Cervical fusion with disc removal
Implanted spinal neurostimulators
Facet joint interventions
For any service or item to be covered by Medicare, it must:
Be eligible for a defined Medicare benefit category.
Be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Meet all other applicable Medicare statutory and regulatory requirements.
Documented subjective patient complaints which justify functional surgery (vision obstruction, unable to do daily tasks, etc.).
Documented excessive upper/ lower lid skin.
Signed clinical notes support a decrease in peripheral vision and/or upper field vision causing the functional deficit (when applicable).
Signed physician’s or non-physician practitioner’s documentation of functional impairment and recommendations.
Documented subjective patient complaints which justify functional surgery (vision, ptosis, etc.).
Supporting pre-operative photos (when applicable).
Visual field studies/exams (when applicable).
Code |
Description |
15820 |
Blepharoplasty, lower eyelid |
15821 |
Blepharoplasty, lower eyelid; with extensive herniated fat pad |
15822 |
Blepharoplasty, upper eyelid |
15823 |
Blepharoplasty, upper eyelid; with excessive skin weighting down lid |
67900 |
Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) |
67901 |
Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) |
67902 |
Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) |
67903 |
Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach |
67904 |
Repair of blepharoptosis; (tarso) levator resection or advancement, external approach |
67906 |
Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) |
67908 |
Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type) |
Note: CPT 67911 (Correction of lid retraction) was removed on January 7, 2022.
PA is only required when one of the required botulinum toxin codes (J0585, J0586, J0587, or J0588) is used in conjunction with the one of the required CPT injection codes (64612, injection of chemical for destruction of nerve muscles on one side of face, or 64615, injection of chemical for destruction of facial and neck nerve muscles on both sides of face). Use of these botulinum toxin codes in conjunction/paired with procedure codes other than 64612 or 64615 will not require PA under this program.
A covered diagnosis.
Dosage and frequency of planned injections.
Specific site(s) injected (refer to LCD/LCA).
Documentation to support the medical necessity when electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s) (when applicable).
To support continuous treatment, the documentation should include the clinical effectiveness of two consecutive treatments that preceded the anticipated procedure (refer to LCD/LCA).
Documentation of the management of a chronic migraine diagnosis. A medical record must include a history of migraine and experiencing frequent headaches on most days of the month.
Documentation of traditional treatments such as medication, physical therapy, and other appropriate methods have been tried and proven unsuccessful (when applicable).
Code |
Description |
64612 |
Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm) |
64615 |
Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine) |
J0585 |
Injection, onabotulinumtoxina, 1 unit |
J0586 |
Injection, abobotulinumtoxina, 5 units |
J0587 |
Injection, rimabotulinumtoxinb, 100 units |
J0588 |
Injection, incobotulinumtoxin a, 1 unit |
Stable weight loss with BMI less than 35 be obtained prior to authorization of coverage for panniculectomy surgery (when applicable).
Description of the pannis and the underlying skin.
Description of conservative treatment undertaken and its results.
The medical records document (s) that the panniculus causes chronic intertrigo or candidiasis or tissue necrosis that consistently recurs over three months and is unresponsive to oral or topical medication (when applicable).
Pre-operative photograph (if requested).
Copies of consultations (when applicable).
Related operative report(s) (when applicable).
Any other pertinent information.
For PARs submitted for CPT 15877, providers should, if applicable, document the main procedure that will be performed on the same day as CPT 15877 in the documentation submitted with the PAR.
Code |
Description |
15830 |
Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy |
15847 |
Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) |
15877 |
Suction assisted lipectomy; trunk |
Medical documentation, with evaluation and management, supporting medical necessity of the service that is to be performed.
Radiologic imaging if done.
Photographs that document the nasal deformity (if applicable).
Documentation supporting unresponsiveness to conservative medical management (if applicable).
Code |
Description |
20912 |
Cartilage graft; nasal septum |
21210 |
Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) |
30400 |
Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip |
30410 |
Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip |
30420 |
Rhinoplasty, primary; including major septal repair |
30430 |
Rhinoplasty, secondary; minor revision (small amount of nasal tip work) |
30435 |
Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) |
30450 |
Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) |
30460 |
Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only |
30462 |
Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies |
30465 |
Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) |
30520 |
Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft |
Doppler ultrasound.
Documentation stating the presence or absence of deep vein thrombosis (DVT), aneurysm, and/or tortuosity (when applicable).
Documented incompetence of the valves of the saphenous, perforator or deep venous systems consistent with the patient's symptoms and findings (when applicable).
Photographs, if the clinical documentation received, is inconclusive.
Documentation supporting the diagnosis of symptomatic varicose veins (evaluation and complaints), and the failure of an adequate trial of conservative management (before the initial procedure) (refer to LCD/LCA).
Code |
Description |
36473 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated |
36474 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites |
36475 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated |
36476 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites |
36478 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated |
36479 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites |
36482 |
Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated |
36483 |
Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites |
Persistent or recurrent moderate or severe arm pain (4 or more on the visual analog scale [VAS] or equivalent) present for a minimum of 12 weeks.
Duration/character/location/radiation of pain.
Activity of daily living (ADL) limitations negatively impacted by nerve compression.
Condition requiring procedure.
Imaging reports pertinent to performed procedure (MRI or CT):
Evidence of stenosis at level corresponding with clinical signs or symptoms and at least one of the below following:
Cervical degenerative disc disease
Congenital short pedicles
Tumors (primary or metastatic)
Infection or Post infection radiographic findings
Ossification of vertebral ligament
Spinal instability
Deformities such as kyphosis, pseudoarthrosis, spondylolisthesis, or rheumatoid arthritis instability
Traumatic injuries including fracturs, dislocations, ligament disruption
Cord compression with or without increased cord signal
Operative report(s) (when applicable).
All other potential sources of pain/neurological deficit have been excluded.
Documented failure to respond to multimodal conservative as defined by the LCD including but are not limited to*:
Combination of medications such as non-steroidal anti-inflammatory (NSAIDs) serotonin and norepinephrine reuptake inhibitors (NRIs), analgesics
Spinal manipulation therapy
Physical therapy
Cognitive behavioral therapy (CBT)
Home exercise program
Acupuncture
Epidural steroid injection
Thermo and cryo therapies
* When imminent surgery is required, and the medical records are submitted without conservative treatment documentation, supporting documentation must be received in the form of imaging report(s), physical findings correlated to the imaging, and the surgeon’s note(s). Please reference LCD specifications for exceptions to conservative therapy requirements.
For more information on the medically reasonable and necessary guidance for decompression of symptomatic cervical nerve root impingement, decompression of symptomatic cervical canal stenosis, and decompression or stabilization of the cervical spine, review the CMS PA Program for Certain Hospital OPD Services – Operational Guide and the LCD and LCA.
Code |
Description |
22551 |
Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 |
22552 |
Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace |
Providers who plan to perform both the trial and permanent implantation procedures using CPT 63650 in the hospital OPD will only be required to submit a PAR for the trial procedure. To avoid a claim denial, providers must place the Unique Tracking Number (UTN) received for the trial procedure on the claim submitted for the permanent implantation procedure. When the trial is rendered in a setting other than hospital OPD, providers will need to request PA for CPT 63650 as part of the permanent implantation procedure in the hospital OPD.
Indicate if this request is for a trial or permanent placement
Physician office notes including:
Condition requiring procedure
Physical evaluation
Treatments tried and failed including but are not limited to:
Spine surgery
Physical therapy
Medications
Injections
Psychological therapy
Documentation of appropriate psychological evaluation:
For permanent placement, include all the above documentation, as well as documentation of pain relief with the temporary implanted electrode(s):
A successful trial should be associated with at least 50% reduction of target pain or 50% reduction of analgesic medications.
Services associated with devices approved under an Investigational Device Exemption (IDE) study must undergo PA and meet the coverage requirements in NCD 160.7.
Code |
Description |
63650 |
Percutaneous implantation of neurostimulator electrode array, epidural |
Note: CPT codes 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver) and 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver) were temporarily removed from the list of OPD services that require prior authorization, as finalized in the CMS-1736-FC.
Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale, and
Presence of pain for minimum of 3 months with documented failure to respond to conservative management, and
Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst), and
Non-facet pathology must be ruled out based on clinical evaluation or radiology studies
The scales used to assess the measurement of pain and/or disability must be obtained at baseline and documented in the medical record for each assessment (refer to LCD/LCA).
Indicate if this request is for an initial or second diagnostic procedure
For the first diagnostic facet joint procedure, documentation must support the criteria
outlined in general documentation requirements for facet joint interventions
Diagnostic procedures should be performed with the intent that if successful, RFA would
be considered the primary treatment goal at the diagnosed level(s)
For the second diagnostic facet joint procedure(s), documentation must support the following:
Documentation must support the requirements for the first diagnostic procedure at the same level, and
After the first diagnostic procedure, there must be at least 80% of pain relief, and
The second diagnostic procedure may only be performed a minimum of 2 weeks after the initial diagnostic procedure. Exception to the two-weeks duration may be considered on an individual basis and must be clearly documented in the medical record
Frequency limitation for IA/MBB: For each covered spinal region, no more than four (4) diagnostic joint sessions will be considered medically reasonable and necessary per rolling 12 months, in recognition that the pain generator cannot always be identified with the initial and confirmatory diagnostic procedure.
Indicate if this request is for an initial or subsequent therapeutic procedure
Documentation of two (2) diagnostic facet joint procedures with each providing at least 80% of pain relief, and
Subsequent therapeutic facet joint procedures at the same anatomic site with at least 50% pain relief for at least 3 months from the prior therapeutic procedure or at least 50% improvement in the ability to perform previously painful movements and ADLs, compared to baseline measurement using the same scale, and
Documentation of why the beneficiary is not a candidate for radiofrequency ablation (RFA)
Frequency limitation: For each covered spinal region no more than four (4) therapeutic facet joint injection (IA) sessions will be reimbursed per rolling 12 months.
Indicate if this request is for an initial or subsequent facet joint denervation procedure
For the initial thermal RFA, documentation must support at least two (2) diagnostic MBBs with each one providing at least 80% of pain relief, and
Subsequent thermal facet joint RFA at the same anatomic site with at least 50% of pain improvement for at least six (6) months and at least 50% improvement in the ability to perform previously painful movements and ADLs, compared to baseline measurement using the same scale
Frequency limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months.
Code |
Description |
64490 |
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level |
64491 |
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level |
64493 |
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level |
64494 |
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level |
64633 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint |
64634 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint |
64635 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint |
64636 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint |
Note: The following CPT codes were removed on August 16, 2024, and no longer require prior authorization:
64492 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s))
64495 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s))
Three (3) or four (4) level procedures are not medically necessary and therefore are non-covered.
