Prior Authorization for Osteogenesis Stimulators

The CMS final rule 42 CFR §§405 and 414., in 2016, established a Prior Authorization (PA) process for certain DMEPOS that are frequently subject to unnecessary utilization.

Prior Authorization will be required for Osteogenesis Stimulators effective for dates of service on and after August 12, 2024. Required PA will be implemented in two phases.

  • Phase one:
    • Required for dates of service on and after August 12, 2024.
    • Required for beneficiaries residing in California, Florida, Ohio, and Pennsylvania.
      • Requests for beneficiaries outside these areas will be rejected.
    • Suppliers may begin submitting requests on July 29, 2024.
  • Phase two:
    • Required for dates of service on and after November 12, 2024.
    • Required Nationwide.
    • Suppliers may begin submitting requests on October 29, 2024.

Prior Authorization Timelines

Policy Initial Review Decision Timeframe Expedited Review Decision Timeframe PAR Decision Valid
Osteogenesis Stimulators 5 business days 2 business days TBD

Access the below related information from this page:

HCPCS Requiring Prior Authorization (PA)

  • E0747 Osteogenesis stimulator, electrical, non-invasive, other than spinal applications.
  • E0748 Osteogenesis stimulator, electrical, non-invasive, spinal applications.
  • E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive.

Documentation Required to Include in Submission to Obtain Prior Authorization

  • Face-to-Face Encounter (F2F)
    • Treating practitioner records that demonstrate the need for the item requested.
  • Written Order Prior to Delivery (WOPD)
  • Any additional medical records providing support for medical necessity.
  • Documentation must be submitted with the PA coversheet for fax, mail, or electronic submission of medical documentation (esMD). For Noridian Medicare Portal (NMP) submissions, complete all required fields. A coversheet is not required for NMP submission.
  • To ensure process efficiency, confirm all components are completed and included within the submission and submitted to the correct jurisdiction.

All PA requests will be reviewed within five business days unless otherwise noted below.

Methods of Submission

Expedited Request Guidelines

In certain circumstances an expedited review may be requested. To be processed as an expedited request, circumstances must be in accordance with the following guidelines:

  • Expedited request must be accompanied by supporting medical documentation to include:
    • Physician indicates clearly, with supporting rationale, that the 5-business day timeframe for an initial decision could jeopardize the beneficiary's health/life.
  • When documentation does not support the above guidelines, expedited requests will be reviewed per the standard timeframe (5-business days).
  • To have a submission considered for expedited review, this must be indicated by using the "expedited request" check box found on either the coversheet or during the NMP submission process.

Avoid Request Rejections

There are assorted reasons why a PA may be rejected and not reviewed. Proper completion of the PA coversheet or ensuring all correct information is entered in the NMP and a thorough intake process aid in minimizing most rejections. Common rejection reasons include:

  • HCPCS code does not require prior authorization.
  • Beneficiary does not reside in this jurisdiction.
  • Duplicate to a previous prior authorization request.

Affirmative and Non-Affirmative Decisions

After the PA submission goes through the medical review process, the supplier will receive a decision letter.

Affirmative

Based on the review, it was determined the beneficiary meets the medical necessity requirements established by Medicare for the orthotic item requested.

Process once an affirmed decision has been received:

  • Deliver item and obtain proof of delivery.
  • Submit the claim.
    • Include the 14-byte Unique Tracking Number (UTN), provided within the decision letter, as indicated below. Each HCPCS code has separate UTN.
    • If billing electronically, include UTN in loop 2300 REF02 (REF01 = G1) or loop 2400 REF02 (REF01 = G1), one UTN submitted per claim line.
  • If billing on CMS-1500 Claim Form, include UTN in Item 23, one UTN per claim form.
Non-Affirmative

Based on the review, supplier has the options below:

  • Review decision and resubmit a PA resubmission.
    • Gather missing and/or clarifying documentation and resubmit.
    • Able to submit unlimited resubmissions.
  • Deliver orthotic and submit claim for denial.
    • Execute Advance Beneficiary Notice of Non-coverage (ABN) prior to delivery, if appropriate
    • File an appeal.
  • Do not deliver or bill

Decision Letters

Treating practitioners involved in the submission of a prior authorization may request a copy of the decision letter.

  • Treating practitioner requesting the letter must be able to demonstrate a legitimate, specific need for information requested.
  • Request may be sent in with PA request or separately.

Still Have Questions?

Call the Supplier Contact Center, Interactive Voice Response (IVR), or Pre-Claim Hotline.

Resources

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