The CMS final rule 42 CFR §§405 and 414., in 2016, established a Condition of Payment Prior Authorization (COPPA) process for certain DMEPOS that are frequently subject to unnecessary utilization. As of dates of service on or after April 13, 2022, five orthoses HCPCS codes now require prior authorization as a condition of payment.

Prior authorization required nationwide as of October 10, 2022

Access the below related information from this page.

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

HCPCS Requiring Prior Authorization (PA)

Spinal Orthoses

• 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
• 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

Documentation Required to Include in Submission to Obtain Prior Authorization

• 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.
• Please note that bilateral knee orthoses PA requests only need to be submitted once; however, the documentation must support the need for bilateral knee 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.
• 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).

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.

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

Situations to Bypass Prior Authorization

In certain situations, there are special modifiers that will cause the claim to bypass prior authorization when billing a claim. These claims will be subject to prepayment review. The following circumstances must apply when appending these modifiers:

• All DME suppliers providing a brace in an acute or emergent situation (with the exception below) must append the ST modifier to the claim
• Exception: Medicare physicians or other treating practitioners IN a Competitive Bid Area (CBA), who are enrolled as Medicare DMEPOS suppliers (without being a competitive bid contract supplier) must append the KV or J5 modifier to the claim only when the following requirements are met:
  • The OTS back brace or OTS knee brace must be furnished by the physician or other treating practitioner to his or her own patient as part of his or her professional service
  • If brace provided prior to surgery or no surgery planned, brace must be medically necessary to be worn at home prior to surgery
  • CMS Update: If brace provided post-surgery, claim should adhere to the following guidelines:
    • If brace provided after surgery, claim must have same date of service (DOS) as surgery
    • If brace provided as part of an unbillable follow-up visit during post-operative period and related to recovery
      • Bill with surgery DOS, or
      • Bill with follow-up visit DOS and include narrative indicating brace applies to same date as surgery
        • Narrative example: Brace associated with surgery DOS 05/01/2023
        • Enter narrative in Item 19 of 1500 claim form or 2400/NTE segment of electronic claim
      • If claim denies, appeal with documentation to support need post-surgery
  • Practitioners and physicians must append KV modifier to claim line in these circumstances
  • Occupational therapists (OT)/physical therapists (PT) must append J5 modifier to claim line in these circumstances
• CMS Update: Appeal rights have been offered for off-the-shelf orthotics furnished by physicians and other treating practitioners in a CBA on DOS January 1, 2021 – December 31, 2023. Braces must have been furnished under the physician exception for these circumstances to allow an appeal:
  • Brace provided at unbillable office visit with KV modifier on claim
  • Brace provided (as necessary part of recovery) at unbillable office visit as part of global services following post-op procedure with KV modifier

Refer to charts below for modifier requirements when bypassing prior authorization

Note: More information about Non-Contract Supplier Exceptions can be found within the Tips section of the Competitive Bidding webpage.

Description of Modifiers to Bypass Prior Authorization

ST Modifier - This modifier is only to be used in acute/emergent situations 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 100% prepayment review.

Note: The ST modifier is not to be used by practitioner/physicians or OTs/PTs who are non-contract suppliers in a competitive bid area furnishing OTS back and knee braces to their own patients.

KV and J5 Modifiers - Physicians/OT/PT who are non-contract suppliers furnishing OTS back and knee braces to their own patients will utilize the KV and J5 modifiers, respectively. In this case, the claim will bypass prior authorization review. 10% of these claims 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.

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) Matters (MM) 6698
• DMEPOS Operational Guide