January 6, 2017

Initial Prior Authorization Program Does Not Include Prosthetic Codes

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On December 21, 2016, the Centers for Medicare & Medicaid Services (CMS) published a rule in the Federal Register announcing that the first phase of its prior authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items will be implemented effective on March 20. There are only two codes subject to prior authorization at this time, both of which described powered wheelchairs. No prosthetic codes are currently affected.

The prior authorization program was finalized on December 30, 2015, with publication of the rule in the Federal Register. The program establishes a prior authorization process for certain DMEPOS that are “frequently subject to unnecessary utilization,” defined as the “furnishing of items that do not comply with one or more of Medicare’s coverage, coding, and payment rules.” As part of the final rule, CMS created a Master List of 135 affected items, 84 of which are L-Codes that pertain to lower-limb prostheses and components. However, the initial implementation of the program would affect a subset of items, called the Required Prior Authorization List, with CMS required to provide 60 days’ notice prior to its implementation.

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