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CGS PAR 801: ASC Blepharoplasty Prior Authorization

Ohio ambulatory surgical centers use this form to ask CGS, the Jurisdiction 15 Medicare contractor, for prior authorization of blepharoplasty under CMS's five-year ASC prior authorization demonstration. The surgeon meets it when eyelid surgery is scheduled for an Original Medicare patient in an Ohio ASC. CGS returns an affirmed or non-affirmed decision with a unique tracking number (UTN) that goes on the ASC's claim.

Who completes it

ASC staff complete the request with the ASC's PTAN and NPI, the beneficiary, and the performing surgeon's name, NPI, fax and address, answering the clinical questions from the surgeon's documentation. CMS also lets a physician or practitioner submit the request on the ASC's behalf.

Submitting and payment

How to submit it
Submit before the procedure through the myCGS portal (preferred), esMD, fax or mail. CGS decides initial requests and resubmissions in 7 calendar days, and justified expedited requests in 2 business days.
Who pays
With an affirmed UTN on the ASC claim, Medicare will likely pay if all other requirements are met; a claim tied to a non-affirmed decision will deny, with appeal rights.

Good to know

  • Q1 lists the functional indications CGS looks for, such as visual field interference affecting reading or driving, difficulty fitting spectacles, debilitating eyelid irritation, or problems wearing a prosthesis with an anophthalmic socket.
  • Photographs and a physical examination must be in the submitted documentation, and the record should show the patient's desire for surgical correction; a No on either weakens the request.
  • Ohio ASCs could submit from February 2, 2026, for dates of service on or after February 16, 2026. Decisions and UTNs are valid for 120 days and one date of service.
  • An ASC may skip prior authorization, but the claim is then suspended for prepayment review with a 45-day records request. Hospital outpatient blepharoplasty uses the separate PAR 251.

Get the official form

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

Prior Authorization ASC: 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

What documentation does CGS need for an ASC blepharoplasty prior authorization?

Medical records showing a functional indication from the Q1 list, photographs, a physical examination, and documentation of the patient's desire for surgical correction. Page 3 of PAR 801 gives space for the condition, associated symptoms and rationale for the procedure, and up to four CPT codes can be requested with one primary diagnosis.

Can the surgeon submit the ASC prior authorization request?

Yes. The ASC is the provider subject to the demonstration, but CMS allows a physician or practitioner to submit the request on the ASC's behalf. Whoever submits it must share the decision and UTN with the other providers involved, and the UTN is reported on the ASC claim only.

What happens after a non-affirmed blepharoplasty decision?

The ASC can add documentation and resubmit as many times as needed before billing, entering the UTN of the most recent submission. A non-affirmation itself cannot be appealed; if the ASC bills anyway, the claim denies and normal appeal rights apply.