Medicare 2026

Eight More Botulinum Toxin Codes Will Need Hospital Outpatient Prior Authorization Starting July 1, 2027

Medicare is expanding a prior authorization process that has been in place at hospital outpatient departments for several years. In the CY 2027 hospital outpatient final rule, published in the Federal Register on November 6, 2026, the Centers for Medicare & Medicaid Services (CMS) added eight botulinum toxin injection codes to the list of services that require prior authorization when performed in a hospital outpatient setting. The change applies to services provided on or after July 1, 2027.

If you or a loved one receives botulinum toxin injections at a hospital outpatient department, here is what the change means, what it does not mean, and how it fits into the bigger Medicare picture heading into 2027.

What hospital outpatient prior authorization is

Prior authorization in the hospital outpatient department is a step where the hospital sends documentation to Medicare before performing certain procedures, showing the service meets Medicare's coverage, coding and payment requirements. If the request gets a "provisional affirmation," the claim is expected to be paid when submitted correctly. If the request is not affirmed, the hospital can resubmit with more information, or the service can still be performed, but the claim is likely to be denied.

This process has applied since July 1, 2020 to blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation. CMS added cervical fusion with disc removal and implanted spinal neurostimulators on July 1, 2021, and facet joint interventions on July 1, 2023. The 2027 change expands the botulinum toxin category to include eight more codes.

Why CMS says it is making this change

CMS pointed to utilization data showing that claims for the added botulinum toxin codes rose 42.8 percent from 2017 to 2024, while overall hospital outpatient claims fell 8.3 percent. The agency uses prior authorization in this setting to help ensure services are medically necessary before they are furnished.

Importantly, CMS states that prior authorization does not prohibit or limit coverage of medically necessary botulinum toxin injection services that meet Medicare's coverage, coding and payment requirements. The procedure for botulinum toxin injection into the bladder is not among the eight added codes.

What patients need to do

In most cases, the answer is: not much directly. The provider submits the prior authorization request, including the documentation showing the service meets Medicare's rules. The request must be sent before the service is provided and before the claim is submitted.

It is still smart to:

• Ask your hospital or clinician whether your scheduled procedure falls under the prior authorization list and whether the request has been submitted.
• Keep copies of any medical records or letters of medical necessity.
• Ask about the expedited 2-business-day review if waiting could seriously jeopardize your life, health or ability to regain maximum function.

CMS says standard requests are generally reviewed within 7 calendar days and have averaged 3.6 days over the past year. CMS also says it intends to provide education and implementation guidance well in advance of the July 1, 2027 effective date.

Provider exemptions

Under CMS's current annual assessment process, a provider that submits at least 10 prior authorization requests and gets provisional affirmations for at least 90 percent of its initial requests may qualify for an exemption from submitting further requests while the exemption is in effect. CMS may also withdraw an exemption. If your hospital is exempt for a given service, you may not notice any paperwork change at all.

How this fits into your 2027 Medicare picture

Prior authorization in the hospital outpatient department applies under Original Medicare (Part A and Part B). Medicare Advantage plans run their own prior authorization programs separately. As you think about coverage for 2027, keep these national facts in mind:

• The Part D out-of-pocket cap is $2,400 in 2027 (up from $2,100 in 2026).
• The most any Part D plan may charge as a deductible in 2027 is $700.
• The Part D base beneficiary premium for 2027 is $41.33, a national figure used to calculate the late-enrollment penalty; actual plan premiums are set plan by plan.
• Social Security announced a 3.6 percent cost-of-living adjustment for benefits payable beginning January 2027.
• The 2027 Part B standard premium and deductible, and the IRMAA income brackets, have not yet been announced; CMS typically releases them in the fall.

Choosing between coverage paths — neutrally

Some people use Original Medicare, often paired with a stand-alone Part D plan and sometimes a Medigap policy, which offers broad provider access and predictable supplemental coverage but typically separate premiums. Others choose a Medicare Advantage plan, which bundles benefits and may include extras but uses networks and its own prior authorization rules. Neither path is "better" for everyone; the right fit depends on your health, providers and budget.

Enrollment windows worth knowing

The Annual Enrollment Period for 2027 coverage runs October 15 – December 7, 2026, with choices taking effect January 1, 2027. People with Medicaid or Extra Help have a monthly Special Enrollment Period to move to Original Medicare with a stand-alone Part D plan or to switch stand-alone Part D plans, and full-benefit dual-eligible individuals may join an integrated D-SNP in any month.

Where to get official help

For plan details, coverage rules and personalized information, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, available 24 hours a day, 7 days a week.