CMS is removing the Medicare prior authorization (PA) requirement for several types of medical equipment because the items no longer meet the standard set forth in a 2015 final rule. Under these regulations, CMS requires PA for certain items of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) that the agency characterizes as “frequently subject to unnecessary utilization” if the items meet a certain cost threshold. While the cost threshold was originally set at an average purchase fee of at least $1,000 or an average monthly rental fee of at least $100, this amount is adjusted annually for inflation. After applying inflation adjustments for 2017 and 2018, the new thresholds are $1,018/purchase and $102/monthly rental. Four items on the current “Master List of Items Frequently Subject to Unnecessary Utilization” no longer meet these cost thresholds:

  • E0260 Hospital bed semi-electric (head and foot adjustment) with any type side rails with mattress
  • E0601 Continuous Airway Pressure (CPAP) Device
  • E1390 Oxygen Concentrator
  • K0004 High strength, lightweight wheelchair

CMS therefore is removing these items from the Master List – and associated PA requirements — effective April 30, 2018.