CMS Announces Initial Implementation of Prior Authorization Program-No Prosthetic Codes Included


On December 19, 2016, the Centers for Medicare and Medicaid Services (CMS) announced the initial implementation of the Medicare prior authorization program that was authorized through the final rule published on December 30, 2015.

As expected, CMS has chosen a cautious approach in implementing its prior authorization program.  The initial list of codes subject to prior authorization only contains 2 codes, both of which describe power wheelchairs.  The two codes selected are:

-K0856–Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds; and
-K0861–Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.

In addition to limiting the number of codes initially subject to prior authorization, CMS has chosen to implement the prior authorization process in two phases.  The first phase will be implemented on March 20, 2017 and will require prior authorization for the two codes above in one state within each DME MAC jurisdiction.  The second phase will be implemented on July 17, 2017 and will expand the prior authorization program for the two codes above nationwide.

While the initial implementation of the Medicare prior authorization program does not include any lower limb prosthetic codes, the expectation remains that prior authorization for most lower limb prostheses will become reality at some point in the future.

AOPA will continue to monitor developments and communicate any new information to its members.

Read the CMS announcement.

Questions regarding this issue may be directed to Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org