8 DME Codes Added to Medicare Prior Authorization List

WASHINGTON—The Centers for Medicare & Medicaid Services (CMS) has added eight HCPCS codes to the list of those requring prior authorization for Medicare billing, including a bed, a wheelchair and several orthoses. 

CMS issued updates to its Master List, the library of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee-for-service codes flagged as potential vulnerabilities for waste, fraud or abuse. Implementation of updates to the Master List, the Required Face-to-Face Encounter and Written Order Prior to Delivery List and the Required Prior Authorization List, excluding upper limb orthoses, are effective Oct. 28.

According to the information published in the July 30 edition of the Federal Register, prior authorization requirements for the upper limb orthoses will be implemented in three phases: phase one includes New York, Michigan, Florida and California and is effective Oct. 28. Phase two includes the states in phase one and Pennsylvania, Massachusetts, Ohio, Illinois, Texas, Georgia, Arizona and Oregon and is effective Jan. 26, 2027. Phase three includes all states and territories not included in phases one and two and is effective April 26, 2027.

The codes are:

• E0194 (air fluidized bed)
• K0005 (ultralightweight manual wheelchairs)
• L1833 (knee orthosis, adjustable knee joints)
• L0456 (thoracic-lumbar-sacral orthosis, flexible, prefabricated item customized to fit a specific patient)
• L0457 (thoracic-lumbar-sacral orthosis, flexible, prefabricated, off the shelf)
• L0486 (thoracic-lumbar-sacral orthosis, triplanar control, includes carved plaster or CAD-CAM model, custom fabricated)
• L3761 (elbow orthosis)
• L3916 (wrist hand orthosis)

CMS tied the new policies to its continued focus on fraud reduction.

“We believe prior authorization of these eight additional HCPCS codes will help further our program integrity goals of reducing fraud, waste and abuse, while also protecting access to care,” the Federal Register posting read. “In addition, recent enforcement actions by the U.S. Department of Justice have continued to demonstrate broader program integrity risks, including fraudulent billing schemes involving medically unnecessary equipment, the submission of claims lacking documentation of medical necessity and the use of telemarketing arrangements targeting Medicare beneficiaries.”