CMS is adding six types of lower limb prosthetics to the list of equipment subject to Medicare prior authorization (PA) requirements, and extending certain current PA requirements.  Specifically, CMS is requiring PA as a condition of Medicare payment for the following items on the basis of their being “frequently subject to unnecessary utilization”:

  • L5856

The Centers for Medicare & Medicaid Services (CMS) is expanding the types of durable medical equipment (DME), prosthetic, orthotics, supplies (DMEPOS) that are subject to Medicare prior authorization requirements on the basis of being “frequently subject to unnecessary utilization.”  Specifically, CMS announced that it is adding to the Required Prior Authorization List:

  • Seven power wheelchair codes (K0857, K0858, K0859, K0860, K0862. K0863, and K0864), effective July 22, 2019.
  • Five support surface codes (E0193, E0277, E0371. E0372.and E0373), to be implemented in two phases to allow CMS “to identity and resolve any unforeseen issues. . . before nationwide implementation.” During phase one, which begins July 22, 2019, CMS will limit the prior authorization requirement to one state in each of the DME Medicare Administrative Contractor (MAC) jurisdictions, as follows:  California, Indiana, New Jersey, and North Carolina.  In phase two, which begins October 21, 2019, CMS will expand the program to the remaining states.

Separately, CMS announced that it is adding the following items to its “Master List of Items Frequently Subject to Unnecessary Utilization”:
Continue Reading CMS Expands DMEPOS Items Subject to Prior Authorization Due to “Unnecessary Utilization”

CMS is adding 31 power mobility device Healthcare Common Procedure Coding System (HCPCS) codes to the list of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that require prior authorization as a condition of Medicare payment. All of the new codes are currently included in the Medicare Prior Authorization for Power Mobility Devices (PMDs)

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

CMS is extending for another year the Medicare prior authorization program for repetitive, scheduled non-emergent ambulance transport services rendered by ambulance providers in selected states. As previously reported, CMS began testing the three-year Medicare prior authorization model in New Jersey, Pennsylvania, and South Carolina on December 1, 2014. The agency extended the model to

Beginning in March 2017, CMS is phasing in new Medicare prior authorization (PA) requirements for two types of power wheelchairs under a policy adopted in a final rule issued late in 2015. As previously reported, CMS finalized regulations to require Medicare PA for certain durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) items that the agency characterizes as “frequently subject to unnecessary utilization.” CMS issued a “Master List” of equipment that could potentially be subject to this requirement, but the agency did not announce the specific selected items.

In a notice to be published December 22, 2016, CMS has announced the first two codes that will be subject to the new PA requirement:
Continue Reading CMS Announces New Medicare Prior Authorization Requirements for Two Types of Power Wheelchairs

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule to require Medicare prior authorization (PA) for certain durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) items that the agency characterizes as “frequently subject to unnecessary utilization.” Notably, however, key policy decisions — including the items that will initially be subject to PA and final timeframes for review of PA requests – still have not been announced. The final rule, published December 30, 2015, specifies a “Master List” of 135 items that will potentially be subject to PA because the item has been (1) identified in a GAO or HHS OIG national report published in 2007 or later as having a high rate of fraud or unnecessary utilization; or (2) listed in the 2011 or later Comprehensive Error Rate Testing (CERT) DME and/or DMEPOS Service Specific Reports, The Master List is further limited to those items with an average purchase fee of at least $1,000 or an average rental fee schedule of at least $100 (adjusted annually for inflation). The Master List will be “self-updating” annually and published in the Federal Register. Items generally will remain on the list for 10 years. The initial Master List is set forth in table 5 of the final rule.  
Continue Reading CMS Finalizes New Medicare Prior Authorization Rules for DMEPOS Subject to “Unnecessary Utilization,” But Policy Questions Remain

As previously reported, CMS announced in November 2014 that it would test a Medicare prior authorization process for repetitive scheduled nonemergent ambulance transport services in New Jersey, Pennsylvania, and South Carolina. The three-year model began on December 1, 2014. As mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS is

CMS has announced that it is extending its Medicare Prior Authorization for Power Mobility Devices (PMDs) demonstration for three years, through August 31, 2018. This demonstration was launched on September 1, 2012 in seven states that CMS describes as having “high levels of improper payments and incidents of fraud related to PMDs” – California, Illinois,

CMS intends to conduct a three-year Medicare prior authorization model for non-emergent hyperbaric oxygen therapy services in Illinois, Michigan, and New Jersey, where CMS contends there have been high rates of improper payments for these services. Under this model, CMS will require that all relevant clinical or medical documentation requirements are met before services are

In light of government reports finding high utilization and potential improper Medicare payments associated with repetitive scheduled nonemergent ambulance transports, CMS will test a prior authorization model program for these services in New Jersey, Pennsylvania, and South Carolina. CMS defines repetitive ambulance service as medically necessary ambulance transportation that is furnished in 3 round trips

CMS is hosting a conference call on Tuesday, August 12, 2014 to discuss its planned expansion of its current demonstration project testing a prior authorization (PA) process for Medicare power mobility device claims.  This demonstration was launched on September 1, 2012 in seven states with what CMS describes as “high populations of fraud- and

CMS is hosting a Special Open Door Forum on June 17, 2014 to provide an overview regarding new Medicare prior authorization initiatives impacting durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) suppliers and ambulance suppliers. Specifically, the call will cover the Medicare Expanded Prior Authorization Demonstration for Power Mobility Devices (PMDs) Demonstration, the Hyperbaric Oxygen

CMS has just released a proposed rule that would require Medicare prior authorization (PA) for certain Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items that the agency characterizes as “frequently subject to unnecessary utilization.“ As part of the rulemaking, CMS has developed a “Master List” of initial items that it

On June 28, 2012, CMS is holding a Special Open Door Forum on Medicare’s Prior Authorization for Power Mobility Devices Demonstration. Under this demonstration, CMS will implement a prior authorization process for PMD orders for Medicare beneficiaries in California, Florida, Illinois, Michigan, New York, North Carolina, and Texas (states that CMS characterizes as having

On December 29, 2011, CMS announced it is indefinitely delaying implementation of its controversial Recovery Audit Prepayment Review demonstration and the separate Prepayment Review and Prior Authorization for Power Mobility Devices demonstration, both of which were scheduled to begin on January 1, 2012. While CMS has not provided a new target implementation date, CMS states