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CGS PAR 805: ASC Botulinum Toxin Prior Authorization

Under CMS's five-year ASC prior authorization demonstration, Ohio ambulatory surgical centers request CGS approval of botulinum toxin injections for Original Medicare patients with this form before the injection date. It asks whether the indication is medical rather than cosmetic, whether the diagnosis falls in the listed groups, and whether symptoms and failed conservative treatment are documented. The UTN from CGS's decision goes on 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

  • Request at least two codes so both the injection and the drug are covered, for example 64612 with its corresponding J code, and enter the number of units.
  • A No on Q1, medical rather than cosmetic use where botulinum toxin is an accepted treatment, means the injection may not be considered medically necessary.
  • Pages 3 and 4 hold the notes on symptoms or progression of illness (Q3) and the history of failed or conservative treatment measures (Q4).
  • The hospital outpatient version is PAR 252. Without a UTN, the ASC claim is suspended for prepayment review and records are due within 45 days.

Get the official form

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

Prior Authorization ASC: Botulinum Toxin Injection

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

Which diagnoses does the CGS ASC botulinum toxin form list?

Q2 asks whether the beneficiary has dystonia or spasticity; blepharospasm, hemifacial spasm or strabismus; or headache or migraine. If not, the injection may not be considered medically necessary. The request also needs detailed documentation of symptoms or progression and a documented history of failed conservative treatment.

How many codes go on an ASC botulinum toxin request?

At least two, so the request shows both the procedure and the drug: for example, 64612 with the corresponding J code. The form allows up to four codes, one primary diagnosis code, the number of units and the date of service, for one beneficiary per form.

How long is an ASC prior authorization decision valid?

A decision and its UTN are valid for 120 days from the date of the decision letter and apply to one claim or date of service. The UTN is reported on the ASC claim only, so the ASC needs it from whoever submitted the request.