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CGS PAR 255: OPD Vein Ablation Prior Authorization

CGS requires this request before a Kentucky or Ohio hospital outpatient department performs vein ablation for an Original Medicare patient, under CMS's nationwide OPD prior authorization program. Five questions separate cosmetic from venous insufficiency treatment, screen for excluding conditions and check that conservative care came first. CGS sends a decision with a UTN that the hospital reports on its 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

  • Conservative care listed in Q5 includes surgical grade compression stockings of at least 20-30 mmHg, oral venoactive drugs, weight reduction, daily exercise and periodic leg elevation.
  • Q3 exclusions include telangiectasia, acute deep venous thrombosis or obliterated deep veins, severe distal arterial occlusive disease, sclerosant allergy, pregnancy and Klippel-Trenaunay syndrome.
  • A claim billed without a UTN automatically denies, and claims for related anesthesia and physician services may deny as well.
  • Revised August 22, 2023 (originated May 22, 2020). Ohio ASCs request the same service on PAR 802 under the ASC demonstration.

Get the official form

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

Prior Authorization OPD: Vein Ablation

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 cosmetic vein treatment covered through the CGS OPD request?

No. Q1 asks whether the procedure is cosmetic, such as treatment of asymptomatic varicosities, telangiectases or cosmetic sclerotherapy, and a Yes means it is not considered medically necessary. Q2 then asks whether the procedure treats varicose veins or venous insufficiency.

What conservative treatment must be documented before vein ablation?

Q5 asks whether conservative treatments were attempted and lists compression therapy with surgical grade stockings of at least 20-30 mmHg, oral venoactive drugs, weight reduction, a daily exercise plan, periodic leg elevation and other measures. A No answer means the procedure is not considered medically necessary.

How long does a CGS vein ablation decision last?

120 days from the date of the decision letter. Each decision is valid for one claim or date of service, and the UTN goes only on the hospital's Part A outpatient claim (type of bill 13X).