December 18, 2019
AVLS Advises That CMS Will Require Mandatory Prior Authorization for Vein Ablation in Hospital Outpatient Setting
December 18, 2019—The American Vein and Lymphatic Society (AVLS) advised its members who practice in the hospital outpatient setting (“Place of Service 22”) that in the 2020 Medicare Hospital Outpatient Final Rule issued in November, the Centers for Medicare & Medicaid Services (CMS) affirmed that effective July 1, 2020, vein ablation will require (in almost all cases) prior authorization in the formal Hospital Outpatient Prospective Payment System setting.
According to AVLS, this requirement is being implemented by CMS based on their analysis of rising claims on their review period of past years. Impacted procedures are all CPT codes for mechanochemical ablation, radiofrequency ablation, laser ablation, and cyanoacrylate adhesives.
In the rule, CMS outlines a process where providers who show typical and appropriate claims patterns will be able to be relieved of prior authorization once they have a 90-day look-back period of their claims. Medicare contractors will have to implement this review process, and AVLS members should be aware of a future notice from their Medicare administrators on how to apply for this process.
In late September, AVLS commented on this Medicare proposal. The society asked CMS to defer or abandon this action and allow the Medicare contractors to either monitor utilization by their own methods or use the recovery audit process. However, CMS was not convinced and is implementing this vein ablation prior authorization, along with several other procedures where claims have increased in their view beyond rates that would be characteristic of typical claims growth, stated AVLS.