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CGS PAR 251: OPD Blepharoplasty Prior Authorization

Hospital outpatient departments in Kentucky and Ohio send this request to CGS before blepharoplasty and related eyelid procedures for Original Medicare patients, under CMS's nationwide prior authorization program for certain OPD services. Prior authorization is a condition of payment, so the attending physician's documentation must answer the coverage questions before surgery. CGS returns a decision with a unique tracking number (UTN).

Who completes it

Hospital outpatient department staff complete the request with the OPD's PTAN, NPI and type of bill, the beneficiary, and the attending physician's name, NPI, fax and address, answering the clinical questions from the physician's documentation. CMS also lets a physician or practitioner submit on the hospital's behalf.

Submitting and payment

How to submit it
Submit before the service through myCGS (preferred), esMD, or by fax or mail using the Kentucky or Ohio line on the form. CGS decides in 7 calendar days, or 2 business days for justified expedited requests.
Who pays
The hospital reports the UTN on its Part A outpatient claim (type of bill 13X): an affirmed UTN means the claim will likely pay if other requirements are met, while a service billed with no UTN automatically denies.

Good to know

  • Q1 lists functional indications, including visual field loss affecting daily activities, difficulty fitting spectacles, chronic dermatitis from blepharochalasis, debilitating eyelid irritation, and debilitating essential blepharospasm after failed treatment.
  • Photographs and a physical examination must be in the documentation, and the record should note the patient's desire for surgical correction.
  • If the eyelid surgery is non-affirmed or denied, claims for related anesthesia, physician and facility services may also deny, either automatically or after payment.
  • PAR 251 was first issued May 22, 2020, and revised August 22, 2023. Ohio ASCs use the separate PAR 801 under the ASC demonstration.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization OPD: Blepharoplasty

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Is prior authorization required for blepharoplasty in a hospital outpatient department?

Yes. Blepharoplasty is one of the services in CMS's OPD prior authorization program, where an affirmed decision is a condition of payment. A hospital outpatient claim billed without a UTN automatically denies, and related services such as anesthesia may also be denied.

What does CGS check on the OPD blepharoplasty request?

Three questions: whether the beneficiary has a listed functional indication, whether photographs and a physical examination are in the documentation, and whether the medical record shows the patient's desire for surgical correction. Page 3 holds the condition, associated symptoms and rationale for the procedure.

How long is an OPD blepharoplasty decision valid?

A decision and its UTN are valid for 120 days from the date of the decision letter and cover one claim or date of service. Report the UTN on the hospital's Part A outpatient claim only, in the treatment authorization field.