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 .
Required Prior Authorization Listing
Top Reasons for K0856/K0861 PAR Program Non-Affirmations
- The 7-element order does not include a valid face-to-face date.
- The face-to-face examination does not demonstrate the beneficiary's upper extremity function is insufficient to self-propel an optimally-configured manual wheelchair in the home.
- The documentation does not demonstrate the beneficiary meets the coverage criteria for a power tilt and power recline seating system and the system is being used on the power mobility device.
- The documentation does not demonstrate the beneficiary's mobility limitations are due to a nerological condition, myopathy or congenital skeletal deformity.
Last Updated Nov 15, 2017