Skip over navigation

Required Programs

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that would establish a prior authorization process as a condition of payment for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization. The prior authorization process assures that all relevant coverage, coding, and clinical documentation requirements are met before the item is furnished to the beneficiary and before the claim is submitted for payment. This helps ensure that beneficiaries are not held responsible for the cost of items that are not eligible for Medicare payment.

The Master List is the set of 135 DMEPOS items identified as being frequently subject to unnecessary utilization. Presence on the Master List does not automatically create a prior authorization requirement for that item. In order to balance minimizing provider and supplier burden with protecting the Medicare Trust Funds and beneficiary access, CMS will initially implement prior authorization for a subset of items on the Master List (referred to as "Required Prior Authorization List"). CMS will publish the Required Prior Authorization List in the Federal Register with at least 60 days' notice before implementation of prior authorization for those items.

CMS will issue specific prior authorization guidance in sub-regulatory communications. The final rule is currently on display at https://www.federalregister.gov/articles/2015/12/30/2015-32506/medicare-program-prior-authorization-process-for-certain-durable-medical-equipment-prosthetics This link will take you to an external website. .

Required Prior Authorization Listing  

Top Reasons for K0856/K0861 PAR Program Non-Affirmations

Last Updated Nov 15, 2017