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. This program was implemented in three phases based on state. Prior authorization is now required nationwide for the knee and spinal orthoses listed below. Check the Implementation schedule below to determine the implementation date for each state.

Access the below related information from this page.

• HCPCS Requiring Prior Authorization (PA)
• Implementation Schedule
• Documentation to Include in Submission
• Methods of Submission
• Expedited Request Guidelines
• Avoid Request Rejections
• Documentation and Modifier Requirements to Bypass Prior Authorization
• Top Reasons for Non-Affirmation
• Affirmative and Non-Affirmative Decisions
• Decision Letters
• 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

Implementation Schedule

The PA process for the above HCPCS codes was implemented in three phases:

• Phase 1
  • Required for beneficiaries in four states: New York, Illinois, Florida, and California
• Phase 2
  • Required for beneficiaries in an additional twelve states: Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington
• Phase 3
  • Required for beneficiaries nationwide

Documentation to Include in Submission

• 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)
• 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
• Physician indicates clearly, with supporting rationale, that the 5-business day timeframe for an initial decision could jeopardize the beneficiary's life or health

When documentation does not support the above guidelines, expedited requests will be reviewed per the standard timeframe.

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 is not subject to prior authorization
• Beneficiary does not reside in this jurisdiction
• Duplicate to a previous prior authorization request

Documentation and Modifier Requirements to Bypass Prior Authorization

For the HCPCS codes requiring prior authorization there are special modifier requirements, in certain situations, to bypass the prior authorization process when billing the claim.
Claims will be subject to prepayment review for:

• Suppliers NOT in a CBA providing in acute/emergent situations utilize the ST modifier; or
• Practitioners/physicians who are also suppliers NOT in a CBA, so not subject to competitive bid rules requiring provision of the item on the same day as professional office visit, and who are providing a brace in an acute/emergent situation utilize the ST modifier; or
• Suppliers who are also practitioners/physicians or occupational therapists (OT)/physical therapists (PT) IN a competitive bid area and subject to providing item on same day as professional office visit utilize the KV or J5 modifier respectively.

Refer to charts below for HCPCS codes and requirements:

Acute/Emergent Situation NOT in Competitive Bid Area

Modifier appropriate for:

1. Suppliers, or
2. Practitioners/physicians who are also suppliers

• Acute/emergent necessity determined and documented by practitioner

Brace Provided at Office Visit for Immediate Use IN Competitive Bid Area

Modifier appropriate for:

1. Physicians, practitioners, OTs, PTs who are also non-contract suppliers
   1. Furnishing brace to own patient at Part B billable office visit for immediate use - no exceptions

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 life of the beneficiary. The addition of this modifier will cause the claim to bypass the prior authorization program. Claims billed using modifier ST will be subject to 100% prepayment review.

• Suppliers providing in acute/emergent situations utilizing the ST modifier will bypass the prior authorization program.
• Practitioner/physicians who are also suppliers NOT in a competitive bid area may also utilize the ST modifier bypassing the prior authorization program.

J5 and KV modifiers - Physicians/OTs/PTs who are non-contract suppliers in a CBA furnishing OTS back and knee braces to their own patients during the Part B billable office visit must 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.

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.

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

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