Q&A: Documentation standards for prior authorization

Q: Is there a national standard for what documentation must be submitted to Medicare Administrative Contractors (MAC) when requesting prior authorization?

A: CMS currently requires prior authorization for the following five procedures when performed in an outpatient department of a hospital:

• Blepharoplasty
• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein ablation

Note that these same services do not require prior authorization when performed in other settings, such as ambulatory surgery centers.

CMS states that the medical necessity documentation requirements for these services have not changed. There are no national coverage determinations, but there are various Medicare Administrative Contractor (MAC) articles and local coverage determinations (LCD) for some of these services. The requirements are not consistent among the MACs that have developed these policies, which means that there will not be a consistent nationwide standard for what documentation should be submitted to MACs when making requests for prior authorization.

Editor’s note: For more information, see “Ready or not: Hospital outpatient prior authorization is here,” by Valerie Rinkle, MPA, CHRI, in the July 2020 issue of the NAHRI Journal.