Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items

Prior Authorization and Pre-Claim Review Initiatives

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Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items

Background

Prior authorization helps Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers ensure that applicable Medicare coverage, payment, and coding rules are met before DMEPOS items are delivered.

The prior authorization program helps to protect the Medicare Trust Fund from improper payments while ensuring that beneficiaries can receive the DMEPOS items they need in a timely manner.

CMS maintains a Master List of DMEPOS Items that may be subject to one or both of the following prior to delivery:

  • a face-to-face encounter and written order
  • prior authorization requirements

The Master List of DMEPOS Items (PDF) is updated at least once per year.

Timeline & Updates

Updates are provided in reverse chronological order; scroll down for earlier updates.

Update to the Suspension of Prior Authorization Requirements for Orthoses Prescribed and Furnished Urgently or Under Special Circumstances: 08/09/2022

CMS announced in the Federal Register on August 9, 2022 suspension of prior authorization requirements for specified orthoses prescribed and furnished urgently or under special circumstances. Pursuant to 42 CFR 414.234(f), CMS may suspend DMEPOS prior authorization requirement generally or for a particular item or items at any time and without undertaking rulemaking. Due to the need for certain patients to receive an orthoses item that may otherwise be subject to prior authorization when the two day expedited review would delay care and risk the health or life of the beneficiary, we are suspending prior authorization requirements under these limited circumstances:

  • Claims for HCPCS codes L0648, L0650, L1832, L1833, and L1851 that are billed using modifier ST, indicating that the item was furnished urgently.
  • Claims for HCPCS codes L0648, L0650, L1833, and L1851 billed with modifiers KV, J5, or J4, by suppliers furnishing these items under a competitive bidding program exception (as described in 42 CFR 414.404(b)), to convey that the DMEPOS item is needed immediately either because it is being furnished by a physician or treating practitioner during an office visit where the physician or treating practitioner determines that the brace is needed immediately due to medical necessity or because it is being furnished by an occupational therapist or physical therapist who determines that the brace needs to be furnished as part of a therapy session(s).

Prior authorization will continue for these orthoses items (HCPCS L0648, L0650, L1832, L1833, and L1851) when furnished under circumstances not covered in this update, as well as all other items on the Required Prior Authorization List (PDF).

Suspension of Prior Authorization Requirements for Orthoses Prescribed and Furnished Urgently or Under Special Circumstances: 04/12/2022

Pursuant to 42 CFR 414.234(f), CMS may suspend the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) prior authorization requirement generally or for a particular item or items at any time and without undertaking rulemaking. Due to the need for certain patients to receive an orthoses item that may otherwise be subject to prior authorization when the two-day expedited review would delay care and risk the health or life of the beneficiary, we are suspending prior authorization requirements for HCPCS codes L0648, L0650, L1832, L1833, and L1851 furnished under these circumstances:

  • Claims for these HCPCS codes that are billed using modifier ST will not undergo prior authorization and will instead be subject to 100% prepayment review.
  • For suppliers furnishing these items under a competitive bidding program exception (as described in 42 CFR 414.404(b)), claims billed with modifiers KV, J5, or J4 would convey that the DMEPOS item is needed immediately and therefore these modifiers will be accepted in addition to the ST modifier. Ten percent of claims submitted using the KV, J5, or J4 modifiers for HCPCS L0648, L0650, L1833, and L1851 will be subject to prepayment review.

Prior authorization will continue for these orthoses items (HCPCS L0648, L0650, L1832, L1833, and L1851) when furnished under circumstances not covered in this update, as well as all other items on the Required Prior Authorization List (PDF). A Federal Register notice is forthcoming.

Updates to the Master List and Required Prior Authorization List: 01/12/2022

CMS announced in the Federal Register on January 12, 2022, updates to the Master List and the selection of certain lower limb orthoses, lumbar sacral orthoses, and power mobility devices to be subject to required prior authorization, beginning April 13, 2022.

See the Policy Groups section for more information.

See the full list of codes on the Required Prior Authorization List (PDF)
See the full list of codes on the Master List (PDF)

Resumption of Prior Authorization Activities: 7/7/2020

Given the importance of medical review activities to CMS’s program integrity efforts, CMS will resume enforcement of the prior authorization process for Certain DMEPOS items beginning on August 3, 2020, regardless of the status of the COVID-19 public health emergency. For Power Mobility Devices and Pressure Reducing Support Surfaces that require prior authorization as a condition of payment, claims with an initial date of service on or after August 3, 2020 must be associated with an affirmative prior authorization decision to be eligible for payment.

Additionally, prior authorization will be required for certain Lower Limb Prosthetics (L5856, L5857, L5858, L5973, L5980, and L5987), with dates of service on or after September 1, 2020 in California, Michigan, Pennsylvania, and Texas. On December 1, 2020, prior authorization for these codes will be required in all of the remaining states and territories.

Provider Burden Relief FAQs (PDF)

See the full list of codes on the Required Prior Authorization List (PDF).

Final Rule 1713-F: 11/8/2019

On November 9, 2019 the CMS issued a final rule that streamlines regulatory requirements to help simplify DMEPOS payment requirements and reduce provider and supplier burden. This final rule created one harmonized master list of DMEPOS items that may be subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements.

Initial Implementation: 3/20/2017

CMS announced in the Federal Register, as published on December 21, 2016, the selection of two items of durable medical equipment to be subject to required prior authorization, which began on March 20, 2017.

Final Rule 6050-F: 12/30/2015

On December 30, 2015 the Centers for Medicare & Medicaid Services (CMS) issued a final rule that would establish a prior authorization process as a condition of payment for certain DMEPOS items that are frequently subject to unnecessary use. This prior authorization process will help ensure that Medicare patients are not held responsible for the cost of items that are not eligible for Medicare.

Contact and Feedback

CMS values feedback from DMEPOS Prior Authorization stakeholders. We encourage patients and providers to submit feedback via email to DMEPOSPA@cms.hhs.gov.

Policy Groups

Power Mobility Devices (PMDs) Requirements

CMS selected HCPCS codes K0856 and K0861 subject to required prior authorization beginning on March 20, 2017 in Illinois, Missouri, New York, and West Virginia. CMS expanded the required prior authorization of these two codes nationwide on July 17, 2017. On September 1, 2018, an additional 31 PMD codes were selected for required prior authorization nationwide. On July 22, 2019, seven additional PMD codes, K0857, K0858, K0859, K0860, K0862, K0863, K0864, were selected for required prior authorization nationwide. Six additional PMD codes, K0800, K0801, K0802, K0806, K0807, and K0808, were selected for required prior authorization to begin nationwide on April 13, 2022.

Orthoses Requirements

CMS selected five HCPCS codes (L0648, L0650, L1832, L1833, and L1851) subject to required prior authorization. Implementation of this requirement will be completed in three phases. Phase one begins April 13, 2022 in New York, Illinois, Florida, and California. Phase two begins July 12, 2022 in Maryland, Pennsylvania, New Jersey Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington. Phase three begins October 10, 2022 in all remaining states and territories not included in phase 1 or phase 2.

Pressure Reducing Support Surfaces (PRSS) Requirements

CMS selected five HCPCS codes (E0193, E0277, E0371, E0372, E0373) subject to required prior authorization beginning on July 22, 2019 in California, Indiana, New Jersey, and North Carolina. CMS expanded required prior authorization of these codes nationwide on October 21, 2019.

Lower Limb Prosthetics (LLPs) Requirements

CMS selected six HCPCS codes (L5856, L5857, L5858, L5973, L5980, and L5987) subject to required prior authorization beginning September 1, 2020 in California, Michigan, Pennsylvania, and Texas. CMS expanded required prior authorization of these codes nationwide on December 1, 2020.

Page Last Modified:
11/10/2022 03:01 PM