Try for free

CGS PAR 804: ASC Panniculectomy Prior Authorization

Ohio ambulatory surgical centers send this CGS request before a panniculectomy for an Original Medicare patient during CMS's five-year ASC prior authorization demonstration. Five questions cover why the panniculus must be removed, its grade, conservative treatment or functional deficit, and weight stability after bariatric surgery. CGS's decision carries a UTN that the ASC reports on its 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 whether surgery follows significant bariatric weight loss that has stayed stable for 6 months, with the beneficiary at least 18 months after the bariatric operation.
  • Q1 covers panniculectomy done to allow another surgery, such as when tissue is too thick for the longest instruments, a grade 3 or higher panniculus raises wound risk, or with hernia repair.
  • Q2 asks whether the procedure is being done primarily for neck or back pain, appearance, abdominal wall laxity or diastasis recti, or psychological complaints.
  • The hospital outpatient version is PAR 254. Decisions and UTNs remain valid for 120 days and apply to one date of service.

Get the official form

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

Prior Authorization ASC: Panniculectomy

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What does CGS ask about panniculus grade?

Q3 asks whether the panniculus is graded 1 to 5, and Q1 separately mentions a grade 3 or higher panniculus that increases the risk of poor wound healing when panniculectomy enables another procedure. Attach the records documenting the grade, with the condition, symptoms and rationale on page 3.

Is prior authorization required for a panniculectomy in an Ohio ASC?

Participation is voluntary, but an ASC that skips the request has its claim suspended while CGS sends an Additional Documentation Request. The ASC then has 45 days to send records; if nothing arrives by day 46, the claim denies for non-receipt.

How fast does CGS decide an ASC panniculectomy request?

Within 7 calendar days for initial requests and resubmissions. Expedited review, 2 business days, is only for cases where delay could seriously jeopardize the beneficiary's life, health or ability to regain maximum function, and a scheduled surgery date alone does not qualify.