The CMS Final Rule (42 CFR §§ 405 and 414), issued in 2016, established a Prior Authorization (PA) program for selected DMEPOS items that have historically demonstrated high rates of unnecessary utilization. Implementation of prior authorization for specific orthotic HCPCS codes began on April 13, 2022, and there are currently 15 HCPCS codes within the Required Prior Authorization program.

Beginning April 13, 2026, PA will be required nationwide for HCPCS codes L0651, L1844, L1846, L1852, and L1932. Suppliers may submit requests for review beginning March 30, 2026.

Beginning October 28, 2026, PA will be required nationwide for L0456, L0457, L0486 and L1833.

HCPCS codes L3761 and L3916 will be implemented in phases.

• Phase 1: 10/28/2026 (NY, MI, FL and CA)
• Phase 2: 01/26/2027 (PA, MA, OH, IL, TX, GA, AZ and OR)
• Phase 3: 04/26/2027 Nationwide

Access the below related information from this page.

• HCPCS Requiring Prior Authorization (PA)
• Required Prior Authorization Timelines
• Probationary Prior Authorization for Orthoses
• Documentation Required to Include in Submission to Obtain Prior Authorization (PA)
• Situations to Bypass Prior Authorization
• Prepayment Reviews When Bypassing Prior Authorization
• Decision Letters
• Still Have Questions?
• Resources

HCPCS Requiring Prior Authorization (PA)

Prior Authorization Timelines

Probationary Prior Authorization for Orthoses

The Probationary Prior Authorization (PPA) program provides an additional layer of oversight for newly enrolled DMEPOS suppliers and suppliers that have completed a change of ownership. Under this nationwide program, selected items require prior authorization during a one-year provisional period. Beginning October 15, 2026, 40 orthoses HCPCS codes will be added.

Probationary Prior Authorization (PPA) HCPCS codes

Refer to the Probationary Prior Authorization (PPA) page for a full list of HCPCS codes.

Documentation Required to Include in Submission to Obtain Prior Authorization (PA)

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.

Bilateral orthoses - Please note that bilateral orthoses PA requests can be submitted on the same request; however, the medical necessity documentation must support the need for bilateral braces. This can be done on the order with a quantity of two or indicating right and left side, or the medical record documentation indicating the need for two orthoses.

Mirror image codes - PA requests can be submitted on the same request if submitting a prior authorization for a mirror code orthosis because it is unknown whether an off-the-shelf or custom fit brace will be needed until the time of delivery. This should be indicated on the supporting documentation submitted for the prior authorization.

To ensure process efficiency, ensure all components are completed and included within the submission and submitted to the correct jurisdiction.

For documentation requirements, refer to the Browse by DMEPOS Category orthotics web page.

Situations to Bypass Prior Authorization

Due to the need for certain patients to receive an orthosis in an acute/emergent situation or after surgery, that may otherwise be subject to prior authorization, when the 2-day expedited review would delay care and risk the health or life of the beneficiary, prior authorization may be suspended.

• The acute/emergent situation must be documented within the physician's records
• Claims will be billed using the ST modifier and may be subject to a prepayment review.

Prepayment Reviews When Bypassing Prior Authorization

• When a prepayment review occurs, additional documentation is requested in a letter. The supplier has 45 days from the date of the letter to submit the documentation. Once the documentation is received, the DME MAC has 30 days to review for a decision.

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 or Interactive Voice Response (IVR).

Resources

• CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual
• CMS Medicare Learning Network (MLN) Fact Sheet 905364 - Complying with Medicare Signature Requirements
• DMEPOS Operational Guide
• Prior Authorization Process for DMEPOS Items Frequently Asked Questions