Condition of Payment Prior Authorization Program Expands to Include Lower Limb Prosthetics

In December 2016, CMS issued a final rule that established a Condition of Payment Prior Authorization (COPPA) process for certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) that are frequently subject to unnecessary utilization. This process was implemented in March 2017 for two HCPCS codes and expanded to include 45 items as of July 2019.

In November 2019, CMS harmonized previous rulings to create a Master List of DMEPOS items that can be subject to Prior Authorization (PA) and/or Face to Face encounter and Written Order Prior to Delivery per Final Rule 1713-F Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule Amounts, DMEPOS Competitive Bidding Program (CBP) Amendments, Standard Elements for a DMEPOS Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements.

From this Master List, the following Lower Limb Prosthetic (LLP) HCPCS codes will be added to the COPPA list: L5856, L5857, L5858, L5973, L5980, and L5987 for beneficiaries residing in California, Michigan, Pennsylvania and Texas.

DME MACs will begin accepting LLP PA requests under the COPPA program April 27, 2020 for planned dates of service on/after May 11, 2020.

See the Required Prior Authorization Programs webpage for information on PA request submission and education resources.

Last Updated Mar 23, 2020