Prior Authorization for Lower Limb Prosthetics

Due to the CMS final rule 42 CFR §§405 and 414., in 2016, a Condition of Payment Prior Authorization (COPPA) process for certain DMEPOS that are frequently subject to unnecessary utilization was established. In November 2019, CMS standardized regulations regarding Prior Authorization (PA) to create a Master List of DMEPOS that can be subject to PA and/or a Face-to-Face encounter and a Written Order Prior to Delivery.

Lower limb prosthetics (LLP) will join the COPPA program September 1, 2020.

Access the below related information from this page.

2020 Expansion

  • Effective for dates of service on/after September 1, 2020, the COPPA program will be required in four states: California, Michigan, Pennsylvania, and Texas.
  • PA will be required for six LLP HCPCS codes:
    • L5856 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE
    • L5857 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE
    • L5858 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE
    • L5973 ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE, DORSIFLEXION AND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCE
    • L5980 ALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEM
    • L5987 ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLON

Documentation to Include in Submission

  • Standard Written Order
  • Documentation from the medical record to support medical necessity

Note: Suppliers are reminded that Section 1834(h)(5) of the Act states that for purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by orthotists and prosthetists shall be considered part of the individual's medical record to support documentation created by eligible professionals as described in section 1848(k)(3)(B) of the Act.

Documentation from a face-to-face encounter conducted by a treating practitioner, as well as documentation created by an orthotist or prosthetist becomes part of the medical records and if the orthotist or prosthetist notes support the documentation created by eligible professionals described in section 1848(k)(3)(B), they can be used together to support medical necessity of an ordered DMEPOS item. In the event the orthotist or prosthetist documentation does not support the documentation created by the eligible professional, the DME MAC may deny payment.

Documentation must be submitted with the PA Request cover sheet via the Noridian Medicare Portal, fax, mail, or esMD to the appropriate jurisdiction based on the beneficiary's permanent address.

To ensure process efficiency, assure all components are completed and included within the submission.

Expedited Request Guidelines

In very rare emergent 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
  • Physician clearly indicates, with supporting rationale, that the 10-business day timeframe for an initial decision could jeopardize the beneficiary's life or health

When documentation does not support the above guidelines, expedited requests will be downgraded to standard requests.

Avoid Request Rejections

There are various reasons why a PA may be rejected and not reviewed. Proper completion of the PA coversheet and a thorough intake process aids in minimizing most rejections. Common reasons include:

  • HCPCS code is not subject to PA
  • Beneficiary does not reside in Pennsylvania
  • Duplicate to a previous PA request
  • Request sent to the incorrect jurisdiction

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 LLP HCPCS code requested.

Process:

  • Deliver LLP and obtain Proof of Delivery
  • Bill with correct Unique Tracking Number (UTN)
  • If billing on CMS-1500 Claim Form, include UTN in Item 23
  • If billing electronically, include UTN in loop 2300 REF02 (REF01 = G1) or loop 2400 REF02 (REF01 = G1)
Non-Affirmative

Based on the review, a supplier is required to follow-up prior to submitting a resubmission.

Options:

  • Review decision and resubmit a PA request
    • Gather missing and/or clarifying documentation
    • Mark resubmission on the coversheet
  • Deliver LLP 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 the LLP

 

Decision Letters

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

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

Still Have Questions?

Call the Supplier Contact Center or Interactive Voice Response (IVR).

Resources

 

Last Updated Wed, 22 Jul 2020 19:04:10 +0000