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CMS Expands Prior Authorization to Six Lower Limb Prosthetic Codes

On February 11, 2020, the Centers for Medicare and Medicaid Services (“CMS”) announced that six lower limb prosthetic Healthcare Common Procedure Coding System (HCPCS) codes will be subject to prior authorization as a Medicare condition of payment.  The six HCPCS codes (L5856, L5857, L5858, L5973, L5980, L5987) describe additions to three microprocessor-controlled prosthetic knees, a microprocessor-controlled ankle-foot prosthesis, and two prosthetic feet.  CMS officials stated that they do not plan any time soon to expand prior authorization to other O&P codes.

CMS will initially implement prior authorization for these codes in only four states—Texas, Pennsylvania, Michigan, and California—effective May 11, 2020.  CMS will then expand prior authorization nationwide beginning on October 8, 2020.  Once this requirement goes into effect, all claims associated with the six identified HCPCS codes that do not have provisionally affirmed prior authorization will be denied payment.  CMS intends to issue additional guidance regarding its deadlines to respond to prior authorization requests for the aforementioned prosthetic codes.

NAAOP has previously expressed concerns regarding the application of prior authorization to orthoses and prostheses.  O&P fabrication and fitting is a detailed, time- and labor-intensive undertaking that is critical to maximizing the beneficiary’s future function.  Unlike durable medical equipment, which is largely commodity-based, prosthetic care is clinical in nature and service-oriented.  Prior authorization has the potential to interfere with the provision of timely and appropriate care.  Any delay in the prior authorization process will directly result in further delays of treatment, and may led to denials of care.

However, prior authorization appears to remain a priority for the Trump Administration.  On February 10, 2020, President Trump released his fiscal year 2021 budget, which contained a proposal to expand prior authorization “to all Medicare Fee-for-Service items and services.”  Under the President’s proposal, CMS would target “items and services that are at high risk for fraud and abuse, such as inpatient rehabilitation facilities.”  At this time, CMS has not formally proposed a regulation that would implement this budget proposal expanding prior authorization, so it is not yet effective.

In fact, one day after the publication of the President’s Fiscal Year 2021 Budget, CMS Administrator Seema Verma seemingly contradicted the President’s proposal, noting that “[p]rior authorization requirements are a primary driver of physician burnout, and even more importantly, patients are experiencing needless delays in care that are negatively impacting the quality of care they receive.”  She stated that prior authorization has been indefensible for years and that she planned to reform or restrict prior authorization this year.  The inconsistent message strikes a discordant tone as CMS implements prior authorization of these six prosthetic codes.

NAAOP will continue to monitor the implementation of prior authorization to the affected prosthetic codes and update our members and friends as developments occur.

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