Insight · Eye care · Oculoplastics
Blepharoplasty now needs prior authorization in the ASC too.
Hospital outpatient departments have needed Medicare prior authorization for eyelid surgery since July 2020. Since January 19, 2026, ASCs in 10 states are in a 5-year demonstration for the same codes. The rules differ by setting, and a missed request costs the surgeon and anesthesia claims too.
By ASP-RCM Editorial, Healthcare RCM Practice · Updated
The question for your oculoplastics team
If the ASC skips the prior authorization request, who else on the case gets their claim held?
States in the ASC demonstration
CA, FL, TN, PA, MD, GA, NY from Jan 19, 2026. TX, AZ, OH from Feb 16, 2026
Eyelid and brow codes
15820-15823, 67900-67904, 67906 and 67908, in both programs
Initial decision
Calendar days for a standard request. Expedited requests: 2 business days
Affirmation and UTN valid
Counted from the decision date. Surgery after that needs a new request
Two Medicare programs, two different penalties
Both cover Original Medicare only. Medicare Advantage plans run their own rules.
| Hospital OPD program | ASC demonstration | |
|---|---|---|
| Setting | Hospital outpatient departments, all states | ASCs (place of service 24) in 10 states |
| Start | Dates of service from July 1, 2020 | January 19, 2026 or February 16, 2026 by state, for 5 years |
| Legal basis | Condition of payment under 42 CFR 419.82 | Voluntary demonstration |
| Claim with no request | Automatically denied | Stopped for prepayment medical review |
| Exemption | Annual exemption at 90% or more provisional affirmation | CMS says an exemption process will follow |
| Codes added later | Eight more botulinum toxin codes from July 1, 2027 | Includes J0589 from the start |
The eyelid codes that need a request
From the CMS code lists for both programs. 67911 was removed from the OPD list on January 7, 2022, and 67911 and 67950 are not on the ASC list.
| Code | Procedure | 2027 national surgeon fee, facility |
|---|---|---|
| 15820, 15821 | Lower eyelid blepharoplasty, with or without extensive fat pad | $429.07 and $462.67 |
| 15822 | Upper eyelid blepharoplasty | $338.03 |
| 15823 | Upper eyelid blepharoplasty, excessive skin weighting down lid | $458.43 |
| 67900 | Brow ptosis repair | $414.06 |
| 67901-67904, 67906, 67908 | Blepharoptosis repair by technique | 67904: $485.51 |
| 64612, J0585-J0589 | Botulinum toxin for blepharospasm and the drug codes | Botulinum category, same rules |
Fees: CY2027 PFS final rule Addendum B total facility RVUs x $32.6286, national, unadjusted. An illustration, not a contracted rate.
How a request moves through the MAC
Same core steps in both programs. The request must come before surgery and before the claim.
Build the packet
Functional complaint, lid findings, signed impairment note, photos and visual fields when applicable, per your MAC's LCD.
Submit to the MAC
Send to your local MAC by fax, mail or esMD. The MAC will not accept a request after the surgery is done.
Decision and UTN
Provisional affirmation, partial affirmation or non-affirmation in 7 calendar days, each with a unique tracking number.
Bill with the UTN
837 loop 2300 REF G1, or the first 14 positions of item 23 on paper. Non-affirmed? Resubmit, unlimited times.
Score one eyelid request before it goes
These are the documentation elements CMS lists in the ASC operational guide. Your MAC's LCD adds detail.
What happens without an affirmation
ASC claim is held
The MAC sends an additional documentation request. The ASC has 45 days to answer and the MAC has 30 days to decide.
Surgeon and anesthesia claims follow
CMS will deny associated physician and anesthesia claims when the ASC request is non-affirmed or the ASC claim is denied. Each provider appeals on its own.
Only the ASC sends the UTN
Physicians bill as usual with no UTN. Their claims may be held until the ASC claim is decided.
Medicare secondary still counts
When Original Medicare is secondary, the request is still needed, or the claim goes to prepayment review.
Blepharoplasty LCDs by MAC
Final LCDs listed in the Medicare Coverage Database on November 6, 2026. The request packet should match the LCD for your jurisdiction.
| MAC | LCD | Current version effective |
|---|---|---|
| CGS | L33944 Blepharoplasty | November 5, 2026 |
| WPS | L34528 Blepharoplasty, Blepharoptosis and Brow Lift | January 1, 2026 |
| Noridian (JE, JF) | L34194 Blepharoplasty, Eyelid Surgery, and Brow Lift | October 16, 2025 |
| Palmetto GBA | L34411 Blepharoplasty, Eyelid Surgery, and Brow Lift | May 20, 2021 |
| Novitas | L35004 Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow | March 21, 2021 |
| First Coast | L34028 Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow | March 21, 2021 |
Cosmetic or functional: the ABN rules
From the CMS demonstration FAQs and operational guide.
Not medically necessary
- Non-affirmed because criteria are not met
- An ABN must be signed before surgery
- Bill with modifier GA
- Medicare pays nothing on a non-affirmed UTN
Purely cosmetic
- Excluded by statute, not a necessity denial
- An ABN is voluntary, CMS encourages it
- Bill with modifier GX if the patient wants a Medicare claim
- The patient can be billed when Medicare denies
Treat the ASC demonstration like the OPD program: no eyelid case goes on the schedule without an affirmed UTN dated inside 120 days. A skipped request delays the facility claim and puts the surgeon and anesthesia claims at risk.
Questions operators ask next
Which states are in the Medicare ASC prior authorization demonstration?
Ten states. California, Florida, Tennessee, Pennsylvania, Maryland, Georgia and New York started with dates of service on or after January 19, 2026. Texas, Arizona and Ohio started with dates of service on or after February 16, 2026. CMS describes it as a five-year demonstration for Original Medicare ASC claims.
Which blepharoplasty codes need Medicare prior authorization?
Both the hospital OPD program and the ASC demonstration list 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906 and 67908. Botulinum toxin code 64612 and the toxin drug codes are a separate category. 67911 was removed from the OPD list in January 2022.
What happens if an ASC bills blepharoplasty without a UTN?
In the demonstration states the claim is stopped for prepayment medical review. The MAC sends a documentation request, the ASC has 45 days to respond and the MAC has 30 days to decide. Related physician and anesthesia claims are denied if the ASC claim is denied.
Does the blepharoplasty prior authorization apply to Medicare Advantage?
No. CMS says the ASC demonstration applies only to claims submitted to Medicare Fee-for-Service. Medicare Advantage plans set their own prior authorization rules. If Original Medicare is the secondary payer, the ASC still needs the request and the UTN on the claim.
Want a second read on your eyelid surgery requests?
Send us 90 days of blepharoplasty and ptosis cases, requests and remits. A senior ophthalmology billing partner shows where affirmations, UTNs and documentation are failing, in a free 30-minute call with a written gap report after.
Keep reading
Sources
- CMS, Prior Authorization Demonstration for Certain ASC Services (page, code list, operational guide, FAQs)
- CMS, ASC demonstration operational guide, March 3, 2026
- CMS, Prior Authorization for Certain Hospital OPD Services (code list and operational guide)
- Federal Register public inspection, CY2027 OPPS/ASC final rule CMS-1850-FC, Table 102
- CMS Medicare Coverage Database, blepharoplasty LCDs
- CMS, CY2027 PFS final rule CMS-1848-F, Addendum B
Checked November 6, 2026. Program details are from CMS pages and guides current on November 6, 2026; CMS notes code lists may change. Check your MAC's LCD for criteria. General information, not legal advice.