Medicare to Require Prior Authorization for Some Cosmetic Procedures in 10 States

Some Democratic lawmakers and medical practices say the program will add unnecessary burden to doctors and Medicare services.

Jill McLaughlin

Published: 10/14/2025, 3:59:14 PM EDT

Medicare to Require Prior Authorization for Some Cosmetic Procedures in 10 States — Starting in December, Medicare will begin requiring prior authorization for certain cosmetic procedures when performed in ambulatory surgical centers. (Dreamstime/TCA)

Medicare patients who want to get Botox or other cosmetic procedures in some states will need to seek prior approval from the federal government starting Dec. 15.

The Centers for Medicare and Medicaid Services (CMS) will launch its five-year prior authorization demonstration project for select Ambulatory Surgical Center services in 10 states: New York, Georgia, Maryland, Pennsylvania, Tennessee, Ohio, Arizona, Texas, Florida, and California.

The services that will need prior authorization are blepharoplasty for upper eyelids, botulinum toxin (Botox) injections, panniculectomy to remove fat in a patient’s lower abdomen, rhinoplasty (nose job), and vein ablation to treat varicose veins.

While these procedures can be used to treat medical conditions, they are mostly performed for cosmetic reasons.

Anesthesia services to perform the procedures might also require prior authorization, according to the American Society of Anesthesiologists.

The pilot program will help improve the CMS’s methods for investigating and prosecuting fraud, according to the agency.

The 10 states selected for the pilot project are more likely to be involved in fraud and to have a higher number of potentially fraudulent claims, according to CMS.

“We will review the documentation submitted by providers submitting claims for payment, thereby helping to prevent improper payments, including payments representing potential fraud, waste, or abuse,” the CMS stated in a fact sheet.

The government also hopes the program will help reduce patient stress by letting beneficiaries know which items and services are and are not covered by Medicare.

“CMS believes that this prior authorization demonstration will both help protect the Medicare Trust Funds from improper payments and make sure beneficiaries are not hindered from accessing necessary services when they need them,” CMS stated.

Dr. Mehmet Oz speaks during a confirmation hearing with the Senate Finance Committee in the Dirksen Senate Office Building in Washington on March 14, 2025. (Anna Moneymaker/Getty Images) — Dr. Mehmet Oz speaks during a confirmation hearing with the Senate Finance Committee in the Dirksen Senate Office Building in Washington on March 14, 2025. Anna Moneymaker/Getty Images

The agency expects to make decisions within seven days of the request for a standard review and within two business days for an expedited review. The decisions can be appealed.

If a provider in one of the selected states submits a claim to Medicare without going through the prior authorization process, the claim will be stopped for a prepayment medical review.

Some Democratic lawmakers and surgeons have expressed concern over CMS’s expansion of prior authorizations, specifically because the agency will use artificial intelligence (AI) to screen for wasteful or potentially fraudulent procedures.

Forty-two Democratic members of Congress wrote to CMS Administrator Dr. Mehmet Oz, urging him to stop the pilot program.

“The expansion of AI-fueled prior authorization will not improve program integrity in Traditional Medicare,” the lawmakers wrote in a July 31 letter.

The pilot program “opens the door to further erosion of our Medicare system,” the members added.

The Medical Group Management Association (MGMA), a trade association representing medical practices, also says the expansion of Medicare’s prior authorization will add an administrative burden for doctors.

“Prior authorization continually ranks as the number one administrative burden facing medical groups, and one of the hallmarks of traditional Medicare has been the ability for physicians, not government, to determine what’s clinically appropriate for their patients,” Anders Gilberg, MGMA’s senior vice president of governmental affairs, told Healthcare Dive.

From The Epoch Times