Prior Authorization for Orthoses - JD DME

The CMS final rule 42 CFR §§405 and 414., in 2016, established a Prior Authorization (PA) process for certain DMEPOS that are frequently subject to unnecessary utilization. For dates of service on or after August 12, 2024, 10 orthoses HCPCS codes will require prior authorization as a condition of payment.

PA will be required nationwide for HCPCS codes L0631, L0637, L0639, L1843, L1845, and L1951 for dates of service August 12, 2024, and after. Suppliers may submit requests for review July 29, 2024.

On August 12, 2024, knee orthoses L1833 will be removed from required PA.

Prior Authorization Timelines

Access the below related information from this page.

• HCPCS Requiring Prior Authorization (PA)
• Documentation Required to Include in Submission to Obtain Prior Authorization (PA)
• Methods of Submission
• Expedited Request Guidelines
• Situations to Bypass Prior Authorization
• Prepayment Reviews When Bypassing Prior Authorization
• Avoid Request Rejections
• Top Reasons for Non-Affirmation
• Affirmative and Non-Affirmative Decisions
• Decision Letters
• Still Have Questions?
• Resources

HCPCS Requiring Prior Authorization (PA)

Spinal Orthoses

• L0631 - Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
• L0637 - Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
• L0639 - Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
• L0648 - Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
• L0650 - Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Knee Orthoses

• L1832 - Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
• L1833 - Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf
  • The L1833 will no longer require PA for dates of service August 12, 2024, and after. PA will be required for dates of service prior to August 12, 2024.
• L1843 - Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
• L1845 - Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
• L1851 - Knee orthosis, single upright, thigh, and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

Ankle-Foot Orthoses

• L1951 - Ankle foot orthosis, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment.

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

• Face-to-Face Encounter (F2F)
  • Treating practitioner records that demonstrate the need for the item requested
• Written Order Prior to Delivery (WOPD)
  • Must be completed within six (6) months after the required face-to-face encounter
  • See the Standard Documentation Requirements Article (A55426) for all requirements
• Any additional medical records providing support for medical necessity
• 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, assure all components are completed and included within the submission and submitted to the correct jurisdiction.

All PA requests will be reviewed within five business days unless otherwise noted below.

Methods of Submission

• Noridian Medicare Portal (NMP)
  • A coversheet is not required for NMP submission
• Fax
• Mail
• Electronic Submission of Medical Documentation (esMD)

Expedited Request Guidelines

In certain 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 to include:
  • Physician indicates clearly, with supporting rationale, that the 5-business day timeframe for an initial decision could jeopardize the beneficiary's health/well-being
• When documentation does not support the above guidelines, expedited requests will be reviewed per the standard timeframe (5-business days).

Situations to Bypass Prior Authorization

• Append the ST modifier - This modifier is only to be used in acute/emergent situations or after surgery, when the medical need has been established, and when a two-day expedited review would delay care and risk the health or well-being of the beneficiary, suppliers may opt to bypass the prior authorization program. These claims will be billed using modifier ST and will be subject to 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.

Avoid Request Rejections

There are assorted reasons why a PA may be rejected and not reviewed. Proper completion of the PA coversheet or ensuring all correct information is entered in the NMP and a thorough intake process aid in minimizing most rejections. Common rejection reasons include:

• HCPCS code does not require prior authorization
• Beneficiary does not reside in this jurisdiction
• Duplicate to a previous prior authorization request

Affirmative and Non-Affirmative Decisions

After the PA submission goes through the medical review process, the supplier will receive a decision letter.

When applicable, the prior authorization decision and corresponding claim information may remain with the beneficiary (i.e., the prior authorization decision identified via a Unique Tracking Number, or UTN, may transfer between suppliers and jurisdictions). CMS assumes such transfers would be made in accordance with applicable privacy laws.

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, Interactive Voice Response (IVR), or Pre-Claim Hotline.

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