Medicare beneficiaries in ten states will quickly be collaborating in a brand new prior authorization program. The Facilities for Medicare & Medicaid Providers (CMS) is implementing a five-year demonstration venture for prior authorization of sure companies offered in Ambulatory Surgical Facilities (ASCs), beginning in December 2025. The focused companies are procedures that may be medically vital, however may be thought-about beauty procedures.
Beforehand, CMS instituted the same prior authorization course of for a similar procedures in 2020. Nonetheless, the 2020 scheme was nationwide and solely utilized to hospital outpatient division (OPD) companies. This demonstration will solely cowl 10 states, together with: California, Florida, Texas, Arizona, Ohio, Tennessee, Pennsylvania, Maryland, Georgia and New York. It additionally differs from the 2020 initiative by specializing in ASCs.
The preauthorization requirement goes into impact for dates of service on or after December 15, 2025. Suppliers can start submitting prior authorization requests starting on December 1, 2025.
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CMS is altering the timeline, not the necessities
The brand new demonstration program doesn’t change present medical necessity or documentation necessities. As an alternative, it requires the identical info to be submitted earlier than the process is carried out to assist suppliers keep away from declare denials and appeals.
“Prior authorization doesn’t create new medical documentation necessities. As an alternative, it requires the identical info that’s already required to assist Medicare cost, simply earlier within the course of,” CMS mentioned on its web site.
Providers included within the prior authorization demonstration
The demonstration targets particular companies which have proven a major enhance in utilization within the ASC setting. These companies can probably be offered as beauty procedures, reasonably than medical, making them weak to improper use and funds.
The companies to be included within the prior authorization demonstration are:
- Blepharoplasty — eyelid surgical procedure
- Botulinum toxin injections
- Panniculectomy — stomach wall contouring
- Rhinoplasty — nostril restore
- Vein ablation procedures — therapy for varicose veins
For example, a blepharoplasty is the medical time period for eyelid surgical procedure. It’s a widespread beauty process that may rejuvenate the world surrounding your eye by eradicating extra pores and skin from the higher or decrease eyelids. This surgical procedure will also be medically vital when somebody’s imaginative and prescient turns into impaired on account of extreme tissue or droop within the higher eyelids.
And though Botox is synonymous with smoothing wrinkles, it additionally has some FDA-approved medical functions for migraines, overactive bladders and sure muscle spasms.
The aim of the brand new prior authorization
Medicare’s prior authorization plan for sure ambulatory surgical companies is meant to make sure that companies are medically vital and to forestall improper funds and fraudulent billing. This plan follows the same program that is already in place for hospital outpatient departments (OPDs).
“Prior authorization helps CMS to verify companies steadily topic to pointless utilization are offered in compliance with relevant Medicare protection, coding, and cost guidelines earlier than they’re offered…” in keeping with the ASC Demonstration FAQs.
The CMS is taking part in catch-up. After the prior authorizations had been applied for hospital outpatient procedures, there was a shift of those companies out of OPDs to ambulatory surgical services. “These will increase are possible associated to OPD companies shifting to the ASC, because the OPD prior authorization program continues,” the CMS mentioned within the FAQ.
Medicare sufferers who want these companies should not have to attend longer because of the prior authorization course of. Selections can be despatched inside seven days of the request for traditional assessment and two enterprise days for expedited assessment.
Use of prior authorizations in authentic Medicare is rising
This new demonstration does not go so far as the present prior authorization necessities for companies obtained in hospital outpatient departments. Within the OPD setting, cervical fusion with disc elimination, implanted spinal neurostimulators, and side joint interventions are additionally topic to the prior authorization necessities.
As soon as a rarity in authentic Medicare, the usage of prior authorization to determine and scale back improper billing and fraud is increasing. In 2026, six states — New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington — will start utilizing the Wasteful and Inappropriate Service Discount (WISeR) Mannequin to carry out prior authorization evaluations for 17 companies that CMS says “are weak to fraud, waste and abuse.”
