CMS Adds Prior Authorization for New Providers

WASHINGTON—The Centers for Medicare & Medicaid Services (CMS) announced it will require probationary prior authorization for some durable medical equipment (DME) billed by newly enrolled suppliers and suppliers undergoing certain changes of ownership. The new requirement begins Oct. 15.

CMS said this program is authorized under Section 1866(j)(3) of the Social Security Act and 42 CFR §424.527, which establishes a one-year probationary period for newly enrolled and ownership-changing DMEPOS suppliers. The agency said suppliers with an enrollment date or ownership change effective on or after Oct. 15 must submit a prior authorization request before delivering any of the DME, prosthetics, orthotics or supplies (DMEPOS) items listed on the CMS Probationary Prior Authorization List.

“Prior authorization allows suppliers to ensure that a DMEPOS item meets applicable Medicare coverage, payment and coding rules before items are delivered,” CMS said on its website. “This advance review 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.”

The impacted HCPCS codes are as follows (descriptions are abbreviated here):

• E0747, E0748: Osteogenesis stimulators
• L0626, L0627, L0628, L0641, L0642: Lumbar orthoses
• L0630, L0633, L0635, L0643, L0649: Lumbar-sacral orthoses
• L0720: Cervical thoracic lumbar sacral orthoses
• L1652, L1653, L1686: Hip orthoses
• L1690: Combination, bilateral, lumbo-sacral, hip, femur orthosis
• L1810, L1812, L1820, L1821: Knee orthoses
• L1902: Ankle orthosis
• L1906, L1971: Ankle foot orthoses
• L2035, L2132, 2134, 2136: Knee ankle foot orthoses
• L3660, L3670: Shoulder orthoses
• L3760, L3762: Elbow orthoses
• L3809: Wrist hand finger orthosis
• L3908, L3915: Wrist hand orthoses
• L3960: Shoulder elbow wrist hand orthosis
• L4360, L4361: Walking boots
• L4396, L4397: Static or dynamic ankle foot orthoses