Prior authorization (PA) has become a routine part of surgical reimbursement across many ophthalmology subspecialties. For ambulatory surgery centers (ASCs), authorization requirements can affect scheduling timelines, documentation expectations, and revenue-cycle workflows. 

Two developments are driving this shift: First, the Centers for Medicare & Medicaid Services (CMS) is expanding PA requirements to certain procedures performed in ASCs through a new demonstration program that started in 2026. Second, the continued growth of Medicare Advantage (MA) plans means more surgical cases require payer authorization before the procedure is performed.

The growth of MA enrollment has increased the use of management tools, such as PA. Medicare Advantage insurers processed nearly 53 million prior authorization determinations in 2024, highlighting the expanding role of authorization requirements in surgical care.¹ As a result, many ophthalmic ASCs are seeing a larger share of surgical cases requiring authorization before patients arrive in the operating room. Understanding which procedures require authorization—and how documentation and coding support approval—can help ASCs reduce reimbursement disruptions.

CMS Expands Prior Authorization to ASC Procedures

CMS first implemented PA requirements on July 1, 2020, for certain eyelid surgeries and botulinum toxin injections performed in hospital outpatient departments. This was meant to reduce improper payments for cosmetic procedures billed as medically necessary functional services. 

In September 2025, CMS announced a 5-year demonstration program expanding these requirements to ASCs. Beginning in early 2026, the program rolled out in 2 phases across 10 states—first in California, Florida, Tennessee, Pennsylvania, Maryland, Georgia, and New York in January, followed by Texas, Arizona, and Ohio in February. Providers in these states may submit PA requests before performing these procedures; if authorization is not obtained, claims may instead be subject to prepayment medical review.²

Ophthalmic Procedures Included in the Program

Several eyelid surgery and botulinum toxin procedures frequently performed by ophthalmologists are included in the demonstration.

Eyelid Surgery CPT Codes 

• 15820 Blepharoplasty, lower eyelid

• 15821 Blepharoplasty, lower eyelid with extensive fat pad removal

• 15822 Blepharoplasty, upper eyelid

• 15823 Blepharoplasty, upper eyelid with excessive skin

• 67900 Repair of brow ptosis

• 67901–67904 Repair of blepharoptosis

• 67906 Superior rectus technique for ptosis repair

• 67908 Conjunctivo-tarso-Müller muscle-levator resection 

Botulinum Toxin CPT Codes* 

• 64612 Chemodenervation of facial nerve muscles (eg, blepharospasm)

• 64615 Chemodenervation for chronic migraine

*Associated botulinum toxin drug codes J0585–J0588 are also included in the authorization process.

These procedures generally require documentation demonstrating that the service is functional rather than cosmetic.³

Determining Who Submits the Authorization

A common operational challenge is determining which entity is responsible for submitting the PA request. CMS allows either the physician office or the ASC to submit the request; however, because physician practices typically maintain the clinical documentation supporting medical necessity, many requests start there. Regardless of who submits the request, ASC facilities must ensure authorization is obtained before the procedure is performed, and clear communication between physician offices and ASC scheduling teams can help prevent missed authorizations. 

Coding and Documentation Considerations 

Coding accuracy plays a key role in obtaining PA approval, because requests typically require CPT codes describing the planned procedure and diagnosis codes supporting medical necessity. For example, authorization for functional blepharoplasty (CPT 15823) often requires documentation demonstrating functional impairment, such as dermatochalasis or blepharoptosis affecting vision, along with other requirements to establish medical necessity per payer policy. Local coverage determinations (LCDs) that outline these requirements for all Medicare administrative contractors (MACs) can be found at aao.org/lcds. When prior authorization is approved, Medicare Part B claims must include the unique tracking number (UTN) assigned to the request, and approvals are generally valid for 120 days.

Documentation Examples

Two common scenarios illustrate PA requirements. In one case, a patient presents with upper eyelid drooping that interferes with activities such as reading and driving. Examination shows significant dermatochalasis with the eyelid resting at the pupil margin. The physician documents visual symptoms and records all payer-specific required findings—such as visual field testing showing superior field obstruction, eyelid photographs, and the margin reflex distance—before submitting a PA request for functional upper eyelid blepharoplasty (CPT 15823). The MAC issues a provisional affirmation allowing the procedure to proceed.

In another scenario, a patient with symptomatic blepharospasm presents with worsening eyelid spasms that impair vision. The physician documents the diagnosis and treatment plan, referencing the applicable MAC policies—including recently finalized LCDs and articles that outline required dosage parameters and clinical assessment tools. A PA request is then submitted for chemodenervation of facial nerve muscles (CPT 64612) with the associated botulinum toxin drug code (J0585). The request is reviewed and provisionally affirmed. For additional guidance, see the blepharospasm section of the Function & Severity (F/S) resources at aao.org/coding-topics.

If these steps are not followed, and there is missing documentation, incorrect coding, or failure to obtain authorization, the request may receive a nonaffirmation or the claim may be denied or subject to prepayment medical review. The checklist below highlights key steps ASC teams can use to help prevent these issues.

Compliance and Potential Exemptions

Although the demonstration program requires PA, CMS allows physicians to qualify for exemptions if they consistently meet documentation requirements. Providers who submit at least 10 PA requests and achieve a 90% provisional affirmation rate during a semiannual review may be granted an exemption.

Preparing ASC Workflows

As PA requirements expand across both Medicare and MA plans, ASC facilities should review scheduling and billing processes to ensure compliance. This may include verifying authorization requirements before scheduling surgery, coordinating closely with physician offices, and tracking authorization decisions within scheduling systems. Establishing consistent authorization workflows can help prevent claim denials, avoid payment delays, and maintain efficient surgical scheduling as payer oversight continues to evolve. OASC 

References

1. Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024 | KFF. Accessed March 9, 2026. https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/#6e420acb-2fc1-4707-8689-ac19594e493a

2. Prior Authorization of Blepharoplasty and Botulinum Toxin Procedures for Ambulatory Surgical Centers and Hospital Outpatient Departments. American Academy of Ophthalmology. Accessed March 9, 2026. https://www.aao.org/practice-management/news-detail/prior-authorization-blepharoplasty-botox-procedure

3. Prior Authorization Demonstration for Certain Ambulatory Surgical Center Services | CMS. Accessed March 9, 2026. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-pre-claim-review-initiatives/prior-authorization-demonstration-certain-ambulatory-surgical-center-services

Matthew Baugh, MHA, COT, OCS, OCSR, is a coding and reimbursement manager for the American Academy of Ophthalmology. Reach him at mbaugh@aao.org.