Prior Authorization Decision Tree
Providers can use this online tool to determine if prior authorization is needed for Medicare Part B covered services.
1. Is prior authorization needed for a prescription drug?
Contact the beneficiary's Part D insurance for further help. Ask the patient for their Medicare Part D card for the appropriate phone number.
2. Is this for a Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT) (Code A0426 or A0428)?
Yes No
Complete a prior authorization request form for services beginning August 1, 2022. Click here for more information: Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT)
3. Do you need prior authorization for one of the codes listed below?
| Blepharoplasty | Botulinum Toxin Injection | *Cervical Fusion with Disc Removal | **Facet Joint Interventions | *Implanted Spinal Neurostimulators | Panniculectomy | Rhinoplasty | Vein ablation |
|---|---|---|---|---|---|---|---|
| 15820 | 64612 | 22551 | 64490 | 63650 | 15830 | 20912 | 36473 |
| 15821 | 64615 | 22552 | 64491 | 15847 | 21210 | 36474 | |
| 15822 | J0585 | 64493 | 15877 | 30400 | 36475 | ||
| 15823 | J0586 | 64494 | 20410 | 36476 | |||
| 67900 | J0587 | 64633 | 30420 | 36478 | |||
| 67901 | J0588 | 64634 | 30430 | 36479 | |||
| 67902 | 64635 | 30435 | 36482 | ||||
| 67903 | 64636 | 30450 | 36483 | ||||
| 67904 | 30460 | ||||||
| 67906 | 30462 | ||||||
| 67908 | 30465 | ||||||
| 30520 |
Outpatient Department Services That Require Prior Authorization
Yes No
Other than RSNATs (Repetitive Scheduled Non-Emergent Ambulance Transports), Medicare Part B does not pre-authorize services. Medicare Part B services are allowed based on medical necessity. Providers should file their claims for the services performed with the appropriate diagnoses. Once the claim is received by Medicare, a determination will be made as to whether it should be allowed based on the information given on that claim.
Note: If you are a Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier, please contact your DME MAC
for further help.
4. Will services be rendered in an hospital outpatient department?
Yes No
5. Will services be rendered in an ambulatory surgery center (ASC) located in Ohio?
Yes No
Certain hospital outpatient department (OPD) services requires prior authorization for dates of services on and after July 1, 2020. Part A hospital OPDs must submit a prior authorization request with supporting documentation, and receive a decision before the service is rendered and claim submitted for processing. Click here for more information Hospital Outpatient Department Prior Authorization.
Prior authorization is not required when rendered in Kentucky. Services allowed are based on medical necessity.
On February 16, 2026, CMS will start a five-year prior authorization demonstration for certain services provided in Part B ambulatory surgical centers located in Ohio. The service categories targeted by the demonstration are blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation. Click here for more information: Prior Authorization: ASC Services
Prior authorization is not required when rendered in Kentucky. Services allowed are based on medical necessity.
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