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CGS PAR 803: ASC Rhinoplasty Prior Authorization

During CMS's five-year ASC prior authorization demonstration, Ohio ambulatory surgical centers use this CGS request before rhinoplasty for an Original Medicare patient. The clinical page is short: it asks whether the nasal deformity stems from a congenital anomaly and whether it causes breathing difficulty. CGS's affirmed or non-affirmed decision carries 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

  • Answering No to both clinical questions, congenital anomaly and breathing difficulty, means the procedure may not be considered medically necessary, so the attached records should document whichever applies.
  • Requests list up to four CPT codes, one primary diagnosis code and the date of service. Incomplete or illegible handwritten forms are returned, and staples should not be used.
  • Submission opened February 2, 2026, for Ohio ASC dates of service from February 16, 2026; the demonstration runs for five years.
  • Hospital outpatient departments use PAR 253 for rhinoplasty under the separate nationwide OPD prior authorization program.

Get the official form

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

Prior Authorization ASC: 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 ASC rhinoplasty form?

Two: whether the beneficiary has a nasal deformity associated with a congenital anomaly, and whether a deformity results in breathing difficulty. Each is answered Yes, No or Not Applicable. If both are No, the procedure may not be considered medically necessary. Page 3 holds the condition, symptoms and rationale.

Who receives the decision letter for an ASC rhinoplasty request?

CGS mails the decision letter to the provider address on file. If the ASC gives a fax number it can also receive the letter by fax, and a fax number is required when the request itself is faxed. The requester must pass the decision and UTN to the other providers.

Do other states use PAR 803?

No. PAR 803 is CGS's Ohio form for Jurisdiction 15. ASCs in other states included in the demonstration send requests to their own Medicare Administrative Contractor, which publishes its own request form for the same services.