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CGS PAR 252: OPD Botulinum Toxin Prior Authorization

Kentucky and Ohio hospital outpatient departments use this CGS request before botulinum toxin injections for Original Medicare patients, because CMS made prior authorization a condition of payment for this OPD service. The form asks whether the use is medical rather than cosmetic, which diagnosis applies, and whether symptoms and failed conservative treatment are documented. The resulting UTN goes on the hospital claim.

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

  • List at least two codes so the request covers both the injection and the drug, such as 64612 with its J code, plus the number of units.
  • Q2 diagnoses are dystonia or spasticity; blepharospasm, hemifacial spasm or strabismus; and headache or migraine. Pages 3 and 4 hold the symptom history and failed-treatment documentation.
  • A decision and UTN are valid for 120 days from the decision letter and apply to one claim or date of service.
  • Revised August 22, 2023 (originated May 22, 2020). Ohio ASCs use PAR 805 for the same service under the separate ASC demonstration.

Get the official form

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

Prior Authorization OPD: Botulinum Toxin Injection

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

What happens if the hospital bills botulinum toxin without a UTN?

The claim automatically denies, and appeal rights apply after the denial. If the HCPCS code is billed with modifier GA, CGS instead suspends the claim and sends an Additional Documentation Request so it can review the Advance Beneficiary Notice.

Which diagnoses does PAR 252 list?

Q2 asks whether the beneficiary has dystonia or spasticity; blepharospasm, hemifacial spasms or strabismus; or headache or migraine. Q1 asks whether the toxin is used for a medical, not cosmetic, indication where it is an accepted treatment. A No to either means the injection may not be considered medically necessary.

Can the treating physician's office submit PAR 252?

Yes. The hospital outpatient department is the provider subject to prior authorization, but CMS allows a physician or practitioner to submit the request on the hospital's behalf. The submitter must share the decision and UTN with the hospital, which reports the UTN on its type of bill 13X claim.