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. Beginning with dates of service on or after April 13, 2022, five orthoses HCPCS codes will require prior authorization in select states as a condition of payment. It will be implemented in three separate phases.

Access the below related information from this page.

• Program Specifics
• Documentation to Include in Submission
• Expedited Request Guidelines
• Avoid Request Rejections
• Documentation and Modifier Requirements to Bypass Prior Authorization
• Affirmative and Non-Affirmative Decisions
• Decision Letters
• Still Have Questions?
• Resources

Program Specifics

Effective for dates of delivery on or after April 13, 2022, prior authorization (PA) will be required in select states for the following HCPCS codes:

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

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

• Phase 1
  • Required for beneficiaries in four states: New York, Illinois, Florida, and California
  • DME MACs will accept requests March 30, 2022, for date of delivery on or after April 13, 2022
• 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
  • DME MACs will accept requests June 28, 2022, for date of delivery on or after July 12, 2022
• Phase 3
  • Required nationwide
  • DME MACs will accept requests beginning September 26, 2022, for date of delivery on or after October 10, 2022

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 providing in Acute/Emergent situations utilizing the ST modifier; or
• Practitioners/physicians who are also suppliers NOT in a competitive bid area, 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 utilizing the ST modifier; or
• Competitive bid suppliers who are also practitioners/physicians or occupational therapist (OT)/physical therapist (PT) IN a competitive bid area and subject to providing item on same day as professional office visit utilizing the KV or J5 modifier.

Refer to chart below for HCPCS codes and requirements:

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, 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.

• Suppliers providing in Acute/Emergent situations utilizing the ST modifier will bypass the prior authorization program. These claims will be subject to 100% prepayment review.
• Practitioner/physicians who are also suppliers NOT in a competitive bid area will also utilize the ST modifier and bypass the prior authorization program. These claims will be subject to 100% prepayment review.

J5 and KV modifier - 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. (The ST modifier is not to be used by practitioner/physicians or OT/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 with 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