CMS turns on prior authorization for ASC services in 10 states
A five-year Medicare demonstration now requires prior authorization for five service categories — including vein ablation and blepharoplasty — with claims subject to prepayment review if centers opt out.
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Fee-for-service Medicare — long the one payer that didn’t make surgery centers ask permission — is piloting exactly that. A CMS demonstration running five years applies prior authorization to ASC claims for five service categories: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation.
The rollout came in two phases this winter: centers in California, Florida, Tennessee, Pennsylvania, Maryland, Georgia, and New York could submit requests from January 5 (for dates of service on or after January 19); Texas, Arizona, and Ohio followed February 2 (dates of service February 16 onward).
Participation is technically voluntary — but the alternative has teeth. Per CMS, “if a provider elects to bypass prior authorization, applicable ASC claims will be subject to a prepayment medical review.” For high-volume vein and oculoplastic centers in the ten states, that’s a choice between authorization friction up front or payment risk on the back end.
The categories mirror CMS’s existing hospital outpatient prior-auth list, which is the tell: this is the agency standardizing utilization controls across settings, not a one-off. Centers outside the ten states should treat the demonstration as a preview.