CMS is adding six types of lower limb prosthetics to the list of equipment subject to Medicare prior authorization (PA) requirements, and extending certain current PA requirements. Specifically, CMS is requiring PA as a condition of Medicare payment for the following items on the basis of their being "frequently subject to unnecessary utilization":
- L5856 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
- L5857 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type
- L5858 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type
- L5973 Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source
- L5980 All lower extremity prostheses, flex foot system
- L5987 All lower extremity prosthesis, shank foot system with vertical loading pylon
CMS is implementing the new PA requirement in two phases. During phase one, which begins May 11, 2020, CMS will impose the PA requirement in one state in each of the DME Medicare Administrative Contractor jurisdictions (California, Michigan, Pennsylvania, and Texas). In phase two, which begins October 8, 2020, CMS will expand the program to the remaining states.
The notice also announces that all 45 Power Mobility Device and Pressure Reducing Support Services items currently on the Required Prior Authorization List will continue to be subject to PA requirements. CMS has compiled information for suppliers about the PA requirements here.
This article is presented for informational purposes only and is not intended to constitute legal advice.
