On January 12, 2022 Centers for Medicaid and Medicaid Services (CMS) announced additions to the prior authorization program for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). The HCPCS codes included with this new addition are the following:
- L0648 - Lumbar-Sacral Orthosis (LSO), Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
- L0650 - Lumbar-Sacral Orthosis (LSO), Sagittal-Coronal Control, With Rigid Anterior And Posterior Frame/Panel(S), Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Lateral Strength Provided By Rigid Lateral Frame/Panel(S), Produces Intracavitary Pressure To Reduce Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
- L1832 - Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise
- L1833 - Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf
- L1851 - Knee Orthosis (KO), Single Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off-The-Shelf
This requirement mandated that prior authorizations for braces be performed for the above codes by both suppliers and providers. “The five codes that will require prior authorization as part of the new process (two spinal and three knee orthoses) are all codes that have high utilization patterns and have been identified as having high potential for fraud and abuse.” (American Orthotic and Prosthetic Association) Phase one of this rollout began April 13, 2022 in New York, Illinois, Florida, and California. Phase two began July 12, 2022 in Maryland, Pennsylvania, New Jersey Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington. Phase three begins October 10, 2022 in all remaining states and territories not included in phase 1 or phase 2.
What does this mean for providers?
On April 12, 2022, CMS released this statement announcing a suspension of the Prior Authorization Requirements for providers given that the orthoses in question need to be furnished urgently:
“Pursuant to 42 CFR 414.234(f), CMS may suspend the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) prior authorization requirement generally or for a particular item or items at any time and without undertaking rulemaking. Due to the need for certain patients to receive an orthoses item that may otherwise be subject to prior authorization when the two-day expedited review would delay care and risk the health or life of the beneficiary, we are suspending prior authorization requirements for HCPCS codes L0648, L0650, L1832, L1833, and L1851...”
Essentially, this waives the requirement for most prior authorizations, allowing providers to make the determination that any item on the Required Prior Authorization List is necessary for their patient’s health and wellbeing.
What does this mean for suppliers?
Durable Medical Equipment (DME) and Orthotic and Prosthetic (O&P) suppliers will be required to submit for prior authorizations prior to dispensing these braces to patients moving forward. Prior authorization requests will be submitted through the DMEMAC administrator portal. Although CMS states that it will take up to 7 days for the approval, they are turning them around typically within 2 business days.