Prior Authorization for Orthoses - JD DME

The CMS Final Rule (42 CFR §§ 405 and 414), issued in 2016, established a Prior Authorization (PA) program for selected DMEPOS items that have historically demonstrated high rates of unnecessary utilization. Implementation of prior authorization for specific orthotic HCPCS codes began on April 13, 2022, with a phased-in rollout involving five codes. The PA requirements were further expanded on August 12, 2024, to include six additional orthotic HCPCS codes, while one previously included code was removed from the program.

Beginning April 13, 2026, PA will be required nationwide for HCPCS codes L0651, L1844, L1846, L1852, and L1932. Suppliers may submit requests for review beginning March 30, 2026.

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)

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

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, ensure all components are completed and included within the submission and submitted to the correct jurisdiction.

L0651, L1852, L1932

• Medical record documentation justifying payment
  • The medical record is not limited to treating practitioner's office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive).
• Standard Written Order (SWO)

L0631, L0637, L0639, L0648, L0650, L1832, L1843, L1844, L1845, L1846, L1851, L1951

• Face-to-Face Encounter (F2F)
  • The face-to-face encounter must support payment for the item(s) ordered/prescribed, and be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans or other sources of information that may be appropriate). The supporting documentation must include subjective and objective beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.
• 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

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

Expedited requests must include supporting medical documentation demonstrating that the standard five-business-day review timeframe could jeopardize the beneficiary's health or well-being. The physician must clearly state this concern and provide rationale within the submitted documentation

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

Due to the need for certain patients to receive an orthosis in an acute/emergent situation or after surgery, that may otherwise be subject to prior authorization, when the 2-day expedited review would delay care and risk the health or life of the beneficiary, prior authorization may be suspended.

• The acute/emergent situation must be documented within the physician's records
• Claims will be billed using the ST modifier and may be subject to a 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 several circumstances in which a prior authorization (PA) request may be rejected without being reviewed. Ensuring the PA coversheet is completed accurately, all required information is correctly entered into the Noridian Medicare Portal (NMP), and a thorough intake process is followed can help reduce these occurrences.

Common reasons for rejection include:

• The HCPCS code submitted does not require prior authorization.
• The beneficiary does not reside within the applicable jurisdiction.
• The request is a duplicate of a previously submitted prior authorization.
• There is already an affirmative, identical, prior authorization request within the validation period on file.

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 or Interactive Voice Response (IVR).

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