Prior authorization is no longer required for certain DME when it risks the health of the patient.
The Centers for Medicare & Medicaid Services (CMS) has suspended the prior authorization requirements for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when waiting for prior authorization would delay healthcare and risk the life or health of the patient.
As of April 13, 2022, prior authorization is no longer required for specified orthoses items that used to require prior authorization as a condition of payment under certain circumstances when reported with certain modifiers. (This does not apply to items subject to a face-to-face encounter and written order prior to delivery requirements.)
Prior to this year, section 1834(a)(15) of the 2015 final rule 80 FR 81674 titled, “Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies,” was implemented. It included a list of DMEPOS items that were often ordered without being medically necessary and were therefore required to have prior authorization.
CMS has concluded, however, that even the two-day expedited prior authorization review for these items could delay care enough to risk the life or health of the patient. As a result, CMS is suspending prior authorization requirements indefinitely under the following limited circumstances:
Claims for HCPCS Level II codes L0648, L0650, L1832, L1833, and L1851 that are billed using modifier ST, indicating that the item was furnished urgently.
Claims for HCPCS Level II codes L0648, L0650, L1833, and L1851 billed with modifiers KV, J5, or J4, by suppliers furnishing these items under a competitive bidding program exception (as described in 42 CFR 414.404(b)), to convey that the DMEPOS item is needed immediately either because it is being furnished by a physician or treating practitioner during an office visit where the physician or treating practitioner determines that the brace is needed immediately due to medical necessity or because it is being furnished by an occupational therapist or physical therapist who determines that the brace needs to be furnished as part of a therapy session(s).