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CGS PAR 802: ASC Vein Ablation Prior Authorization

Ohio ambulatory surgical centers use this CGS request to obtain Medicare prior authorization for vein ablation under CMS's five-year ASC demonstration. Its questions separate cosmetic treatment from treatment of varicose veins or venous insufficiency, screen for conditions that rule the procedure out, and ask about conservative care. CGS returns a decision with a UTN for the ASC 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

  • Q5 asks which conservative treatments were tried: surgical grade compression stockings of at least 20-30 mmHg, oral venoactive drugs, weight reduction, daily exercise, periodic leg elevation or other measures.
  • Q3 lists conditions that make the procedure not medically necessary, including spider veins, acute deep venous thrombosis, inability to tolerate compression, severe distal arterial occlusive disease and pregnancy.
  • Treatment of asymptomatic varicosities, telangiectases or cosmetic sclerotherapy answers Yes to Q1, which the form says is not considered medically necessary.
  • The hospital outpatient version is PAR 255. An ASC claim billed without a UTN is suspended for prepayment review, with records due in 45 days.

Get the official form

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

Prior Authorization ASC: 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

What conservative treatment does CGS ask about for vein ablation?

Q5 asks whether conservative treatments were attempted, listing 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.

Which conditions rule out vein ablation on the CGS form?

Q3 lists spider veins or telangiectasia, inability to tolerate compression, severe distal arterial occlusive disease, Klippel-Trenaunay syndrome or other congenital venous abnormalities, obliterated deep veins or acute deep venous thrombosis, sclerosant allergy, pregnancy, and advanced systemic disease limiting expected benefit. A Yes means not medically necessary.

Can an ASC resubmit a non-affirmed vein ablation request?

Yes, without limit, before submitting the claim. Choose the resubmission request type and enter the UTN of the most recent submission; resubmissions are reviewed within 7 calendar days. A non-affirmed request cannot be appealed, but a denied claim carries normal appeal rights.