Prior authorization required for preferred viscosupplementation products

Prior authorization must be obtained for the three preferred viscosupplementation products before administration: Durolane (J7318), Gel-One (J7326), and Euflexxa (J7323).

• Include prior authorization request for the specific HCPCS J-code (J7318, J7326, or J7323).
• If requesting a non-preferred product, submit medical necessity documentation with the authorization request.

Obtain prior authorization for listed procedures and services

Obtain prior authorization for procedures and services that are labeled 'Prior Authorization Required' in the notice before performing or billing the service.

• This requirement applies to office, homecare, or hospital-based services where indicated.
• Submit clinical documentation supporting the medical necessity of the requested service.

Prior authorization required for listed services (some post-threshold)

Providers must request prior authorization for the listed services; certain services require authorization only after the visit threshold is exceeded.

• Follow the visit-count rule where noted (see related callouts for threshold).
• Include clinical notes documenting indication and prior treatments when submitting the request.

Prior authorization required for numerous listed services; observe visit thresholds

Prior authorization is required for many of the procedures enumerated in the document; for some services authorization is required only after more than three (3) visits in a calendar year.

• When the > THREE (3) visits threshold applies, obtain prior authorization once the threshold is exceeded for office, homecare, or hospital-based services.
• Provide visit counts and dates as part of the authorization submission when relevant.

Obtain prior authorization for listed ophthalmologic procedures

Specific ophthalmologic procedures listed (for example: blepharoplasty, capsulotomy, corneal relaxing incision, corneal wedge resection) require prior authorization before service.

• Include procedure-specific clinical documentation (diagnosis, prior treatments, and rationale) in the authorization request.
• If the procedure occurs after >3 visits in the calendar year and the listing indicates the threshold, include visit history.

Prior authorization required for numerous listed procedures (cosmetic, interventional, ophthalmic)

Prior authorization is required for the many procedures listed throughout the notice (examples include blepharoplasty, capsulotomy, corneal procedures, epidural injections, facet blocks, rhizotomies, SI joint procedures, and select cosmetic surgeries).

• Submit a prior authorization request with supporting clinical documentation before performing these procedures.
• If the procedure is for a cosmetic indication noted as 'NOT A COVERED BENEFIT', expect non-coverage unless medical necessity is demonstrated and authorized.

Submit prior authorization for the listed procedures before performing service

Prior authorization must be requested for the procedures specifically enumerated (including interventional pain procedures, some eye surgeries, and various elective/cosmetic procedures) before service.

• Ensure authorization is obtained prior to service to avoid claim denial.
• Provide complete clinical rationale and prior treatment history with the request.

Obtain prior authorization when >3 visits per calendar year threshold is exceeded

Certain services require prior authorization only after more than three (3) visits per calendar year (office, homecare, or hospital-based); obtain authorization once the visit threshold is exceeded.

• Track and report the number of visits in the calendar year when submitting an authorization request.
• This visit-threshold rule applies to items explicitly indicated with '> THREE (3) visits' in the notice.

Prior authorization required for listed procedures (confirm visit-threshold applicability)

Providers must secure prior authorization for the listed procedures; some services are designated to require authorization only after the visit-count threshold is met.

• Confirm whether the specific service in question is subject to the >3 visits rule before submitting.
• Attach visit logs and prior treatment documentation when applicable.

Obtain prior authorization for the listed procedures (eye, interventional, elective)

Prior authorization is required for the listed procedures, including many eye surgeries and interventional procedures; obtain authorization before providing the service to prevent non-coverage.

• Examples include blepharoplasty, capsulotomy, corneal procedures, epidural injections, facet blocks, rhizotomies, and SI joint procedures.
• Submit procedure-specific clinical evidence and prior-treatment history with the authorization request.

Request prior authorization after >3 visits per year for applicable services

Prior authorization is required for certain services after more than THREE (3) visits per calendar year (office, homecare, or hospital-based); providers must monitor visit counts and request authorization when the threshold is exceeded.

• Report dates of service and total visit count in the calendar year with the authorization submission.
• This applies where the listing explicitly states 'Prior Authorization Required after > THREE (3) visits per Calendar Year'.

Prior authorization required for interventional and listed services; document approval

Obtain prior authorization for specified procedures and services listed in the notice; failure to obtain authorization may result in denial of coverage or payment.

• Examples include epidural injections (cervical and lumbar), facet blocks, rhizotomies, SI joint procedures, and numerous eye procedures.
• Always document authorization approval in the patient record before performing the service.

Obtain prior authorization for listed procedures; check visit-based exceptions

Prior authorization is required for the listed procedures and services; some items require authorization only after more than three visits in a calendar year—confirm applicability when planning treatment.

• Include clinical notes, prior therapies, and visit history with authorization requests.
• Do not perform or submit claims for listed services without first obtaining authorization when required.

Prior authorization required for listed procedures (general)

Prior authorization is required generally for the listed procedures; when authorization is required post-threshold, obtain approval after the visit-count is exceeded to ensure coverage.

• Document the reason for the procedure and prior conservative treatments in the authorization submission.
• If authorization is not obtained when required, the claim may be denied.

Obtain prior authorization for enumerated services (pain interventions, eye surgeries, elective procedures)

Prior authorization is required for listed services including epidural injections, facet blocks, rhizotomies, SI joint procedures, and various eye surgeries; submit requests prior to service to avoid denial.

• Include operative/procedural indications and prior treatment attempts with the authorization request.
• Cosmetic procedures noted as 'NOT A COVERED BENEFIT' will not be covered unless medical necessity is demonstrated and authorized.

Prior authorization required after >3 visits per calendar year for applicable services

Some services are subject to a prior authorization threshold: authorization is required after more than three (3) visits per calendar year for office, homecare, or hospital-based services; obtain authorization when the threshold is exceeded.

• Provide date-stamped visit counts and clinical progress notes with the authorization request.
• Confirm whether the specific service is flagged with the >3 visits rule before proceeding.

Secure prior authorization for specified procedures and document approval

Prior authorization must be obtained for the specified procedures and services; obtain authorization before providing or billing these items to reduce risk of denial.

• Document authorization approval in the medical record prior to service.
• Submit full clinical documentation with the authorization request.

Obtain prior authorization for listed services; observe >3 visits rule where noted

Prior authorization is required for the listed services; some services require authorization only after more than three (3) visits per calendar year—obtain authorization accordingly.

• Track visit counts and supply them in the authorization submission when the >3 visits rule applies.
• Failure to obtain required prior authorization may result in denial of coverage.

Obtain prior authorization for numerous eye, interventional, and surgical procedures

Prior authorization is required for numerous eye procedures and surgeries (examples: blepharoplasty, capsulotomy, corneal procedures, eyelid repairs, implantation of intraocular devices, keratoplasty, orbital prosthesis) and for procedures such as epidural injections, facet blocks, rhizotomies, SI joint procedures, erectile dysfunction procedures, sclerotherapy, septoplasty, skin tag removal, and panniculectomy.

• Submit procedure-specific clinical documentation and prior-treatment history with the authorization request.
• If a non-preferred product or cosmetic indication is involved, include medical necessity documentation.

Request prior authorization after > THREE (3) visits per calendar year for applicable services

When applicable, obtain prior authorization after more than THREE (3) visits per calendar year for services provided in office, homecare, or hospital settings; track visits and submit counts with the request.

• Provide supporting documentation of visit dates and services rendered when requesting authorization.
• Authorization should be obtained before additional visits beyond the threshold are billed when the rule applies.

Provide medical necessity documentation for non-preferred viscosupplementation products

Requests for non-preferred viscosupplementation products must include supporting documentation demonstrating medical necessity; non-preferred products are not covered unless medical necessity is demonstrated and prior authorization is approved.

• Provide rationale for why preferred products (Durolane J7318, Gel-One J7326, Euflexxa J7323) are not appropriate for this patient.
• Attach relevant clinical records, prior treatment attempts, and contraindications to preferred products.

Include clinical documentation to support prior authorization requests

When submitting prior authorization requests, include clinical documentation that demonstrates medical necessity and supports the requested service or product.

• For procedures labeled 'Prior Authorization Required', provide diagnosis, prior conservative treatments, and procedure rationale.
• If visit thresholds apply, include visit dates and counts in the request.

Submit prior authorization requests for services labeled 'Prior Authorization Required'

Providers must submit a prior authorization request for any service explicitly labeled 'Prior Authorization Required' (office, homecare, or hospital-based) before rendering or billing the service.

• Submit authorization requests through the payer's designated prior authorization process and include all supporting documentation.
• Do not perform or bill for the service until authorization is received when required.

Provide procedure-specific documentation to support prior authorization

Document and attach clinical evidence supporting prior authorization requests for the specific procedures named in the notice (for example, blepharoplasty, capsulotomy, corneal relaxing incision).

• Include diagnosis, prior treatments, imaging, and specialist consultation notes as applicable.
• For non-preferred products or excluded cosmetic indications, clearly document the medical necessity rationale.

Ensure prior authorization and documentation for preferred products and listed procedures

Prior authorization is required for the listed preferred viscosupplementation products and for many cosmetic and procedural services; ensure authorization is obtained before service provision.

• When requesting authorization for a preferred product, include the HCPCS code and supporting clinical information.
• If requesting a non-preferred product, include medical necessity documentation as described.

Attach documented prior authorization and visit history for post-threshold services

Documented prior authorization is required for services after more than three visits per calendar year and for the other procedures listed as 'Prior Authorization Required'; include visit history with the request.

• Provide dates of service and total visit counts when the > THREE (3) visits rule applies.
• Include progress notes and prior treatment responses in the authorization submission.

Submit prior authorization requests for explicitly listed procedures before performing service

Providers must submit prior authorization requests for the procedures and services explicitly listed (examples include blepharoplasty, rhinoplasty, epidural injections, facet blocks, SI joint procedures, panniculectomy) prior to performing the service.

• Use the payer's authorization form or portal and include all required clinical attachments.
• Retain authorization approval reference in the patient chart.

Obtain prior authorization documentation prior to service for listed procedures

Prior authorization documentation for the listed procedures must be obtained before services are provided; do not render or bill listed services without authorization when required.

• Document authorization approval number and date in the medical record prior to service.
• If authorization is retrospective or missing, be aware claims may be denied.

Retain prior authorization approval and supporting documentation in the chart

Keep documentation that verifies prior authorization was obtained when required (authorization number, approval date, and supporting clinical records) in the patient record.

• Maintain authorization reference numbers in the chart to support claims submission.
• Ensure documentation includes the clinical rationale and any visit-count information if applicable.

Obtain prior authorization for listed procedures; document indications

Providers are expected to obtain prior authorization for the listed procedures and services (examples: blepharoplasty, capsulotomy, various ophthalmic and interventional procedures) before delivering care.

• Include prior treatment history and clinical indications with the authorization request.
• If the service is for a cosmetic indication listed as 'NOT A COVERED BENEFIT', document medical necessity if seeking coverage.

Submit prior authorization for enumerated interventional and surgical services before performing them

Providers must obtain prior authorization for the procedures and services enumerated (examples include epidural injections, facet blocks, rhizotomies, SI joint procedures, various eye surgeries); submit requests before performing service.

• Attach clinical notes, imaging, and prior therapy documentation to the authorization request.
• If the requested service exceeds visit thresholds, include visit counts.

Submit prior authorization requests for explicitly listed services before performing or billing

Providers must submit prior authorization requests for the procedures and services explicitly listed as 'Prior Authorization Required' prior to performing the service or submitting claims.

• Use the payer's designated authorization process and include required supporting documentation.
• Do not assume payment without prior authorization when the service is listed as requiring it.

Document authorization for preferred products and post-threshold services

Prior authorization documentation is required for the listed preferred products and procedures; when the visit threshold (> THREE (3) visits per calendar year) is exceeded, prior authorization must be obtained for those services.

• Include HCPCS code, clinical rationale, and visit counts (if applicable) with the authorization request.
• If requesting a non-preferred product, include medical necessity justification.

Request prior authorization before performing procedures labeled 'Prior Authorization Required'

Providers must request prior authorization for procedures explicitly labeled 'Prior Authorization Required' before performing the service; obtain approval to ensure coverage.

• Attach procedure-specific clinical documentation and prior-treatment notes with the request.
• Record authorization details in the medical record upon approval.

Obtain prior authorization for explicitly listed procedures before performing service or billing

Obtain prior authorization for the procedures and services explicitly listed in this section before performing the service or submitting a claim; failure to obtain authorization may result in denial.

• Ensure authorization approval is documented in the chart prior to service.
• If service is non-preferred, include medical necessity documentation with the request.

Non-preferred viscosupplementation products require medical necessity documentation and prior authorization

Requests for non-preferred viscosupplementation products will be considered non-preferred and not covered unless medical necessity is demonstrated and prior authorization is approved.

• When requesting non-preferred product coverage, include documentation that justifies why preferred products are not appropriate.
• Examples of supporting documentation: contraindications to preferred products, prior adverse reactions, or documented treatment failure.

Risk of denial if prior authorization is not obtained

Failure to obtain required prior authorization for listed procedures may result in denial or non-coverage; ensure authorization is obtained before the service when listed as required.

• Do not perform or submit claims for services labeled 'Prior Authorization Required' without prior approval.
• If authorization was not obtained, expect potential claim denial or non-payment.

Failure to obtain prior authorization may lead to denial

Not obtaining prior authorization for any service labeled 'Prior Authorization Required' may result in claim denial; verify authorization status before rendering services.

• Check authorization status via the payer's portal or Provider Customer Service before performing the service.
• Retain approval documentation in the patient record to support billing.

Missing prior authorization risks denial for many listed services

Failure to obtain required prior authorization for the many services identified as 'Prior Authorization Required' (and those that become required after >3 visits) creates a risk of denial or non-coverage.

• Verify whether the service is listed as requiring prior authorization and whether the visit-threshold applies before scheduling or performing the service.
• Include authorization evidence with claims to reduce denial risk.

Risk of denial for lack of prior authorization across listed procedure types

Failure to obtain prior authorization for procedures listed (including cosmetic, interventional pain, and ophthalmologic procedures) may trigger claim denial; obtain authorization before service.

• If a procedure is performed without required authorization, the claim may be denied even if the service was clinically appropriate.
• When in doubt, contact Provider Customer Service to confirm authorization requirements.

Failure to obtain prior authorization for preferred products or procedures may result in denial

If prior authorization is required for the preferred products or listed procedures and is not obtained, coverage or payment may be denied; obtain authorization in advance.

• Prior authorization is required for preferred viscosupplementation products and many procedures—do not assume payment without approval.
• Maintain documentation of authorization approval in the medical record.

Prior authorization required — failure to obtain may result in denial

Not obtaining prior authorization for the listed preferred products or procedures may result in denial; confirm and document authorization prior to service.

• If authorization is denied, do not proceed with the service expecting payment.
• For denied requests, follow payer appeal or exception processes as applicable.

Services submitted without required prior authorization risk denial

Failure to obtain prior authorization when required may result in coverage denial for the services enumerated (including many eye surgeries and interventional procedures); obtain authorization first.

• Document authorization approval numbers and keep supporting clinical records available for claim review.
• If authorization was not obtained, anticipate claim denial or non-payment.

Failure to obtain prior authorization may cause denial for preferred products and listed procedures

Prior authorization is required for the listed preferred products and procedures; failure to obtain prior authorization may result in denial of coverage or payment.

• Confirm authorization requirements and obtain approvals before performing services.
• If a product is non-preferred, include documented medical necessity with the authorization request.

Prior authorization required — risk of denial if not obtained

Failure to obtain prior authorization where required for listed procedures and services may result in denial of coverage or payment; obtain authorization in advance and document it.

• Keep authorization details in the patient chart to support claims submission.
• If authorization is required after a visit threshold, obtain it when the threshold is exceeded to avoid denial.