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CGS PAR 253: OPD Rhinoplasty Prior Authorization

Kentucky and Ohio hospital outpatient departments send this request to CGS before rhinoplasty for an Original Medicare patient, under CMS's nationwide OPD prior authorization program. The clinical page asks only two questions, about congenital nasal deformity and deformity causing breathing difficulty, so the attending physician's attached records carry most of the weight. CGS's decision includes a UTN for 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

  • If the answer to both clinical questions is No, the rhinoplasty may not be considered medically necessary; page 3 holds the condition, symptoms and rationale.
  • Type of bill and date of service are required, along with up to four HCPCS codes and one primary diagnosis code for a single beneficiary.
  • The fax number on the request must be the hospital outpatient department's own; the decision letter is also mailed to the provider address on file.
  • Revised August 17, 2023 (originated May 22, 2020). Ohio ambulatory surgical centers use PAR 803 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: Rhinoplasty

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 clinical questions are on the CGS OPD rhinoplasty form?

Two: whether the beneficiary has a nasal deformity associated with a congenital anomaly, and whether a deformity results in breathing difficulty. Each can be answered Yes, No or Not Applicable. If both are No, the procedure may not be considered medically necessary.

How quickly does CGS decide an OPD rhinoplasty request?

Within 7 calendar days for initial requests and resubmissions. Expedited review, 2 business days, is reserved for situations where delay could seriously jeopardize the beneficiary's life, health or ability to regain maximum function; a scheduled procedure date alone does not justify it.

Can a non-affirmed rhinoplasty request be appealed?

No. A non-affirmation is not an initial payment determination, so it carries no appeal rights. The hospital can resubmit with more documentation as many times as needed, or bill the claim, which will deny and then carry normal appeal rights.