On Friday, February 7, the Centers for Medicare and Medicaid Services (CMS) announced that six lower limb prosthetic codes will be added to the codes that require Medicare prior authorization as a condition of payment. The official announcement was published today, February 11 in the Federal Register.
AOPA has actively communicated concerns about Medicare prior authorization and its potential to cause unnecessary delays in timely and efficient O&P care with CMS, through the submission of formal comments and during in-person meetings with CMS officials. In response, prior to the release of this Federal Register publication, AOPA received an e-mail communication from a high-ranking CMS official that addressed its concerns. Specifically, the e-mail communication stated the following:
- CMS does not intend to significantly expand the number of lower limb prostheses subject to prior authorization in the future.
- CMS understands the need for timeliness in making prior authorization decisions.
- DME MACs will provide education to providers when prior authorization requests are not initially approved.
- Affirmative prior authorization decisions will guarantee payment and reduce likelihood of audits down the road.
AOPA is encouraged by CMS’ efforts to address its previously stated concern regarding prior authorization and will closely monitor the prior authorization process to ensure that it does not lead to unnecessary delays in delivery of clinically appropriate prosthetic care to Medicare beneficiaries. The initial implementation of prior authorization for the six codes, scheduled for May 2020, will occur on a very limited basis in one state in each of the four DME MAC jurisdictions (Pennsylvania, Michigan, Texas, and California). Nationwide implementation is scheduled for late 2020. The six codes that will require Medicare prior authorization are:
| HCPCS | Description |
| 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 |
The selected codes represent three microprocessor based prosthetic knees, a microprocessor based prosthetic foot, and two functional level 3 prosthetic feet.
AOPA will continue to monitor communications from CMS and the DME MAC contractors regarding the Medicare prior authorization process and will provide additional education to AOPA members as more details regarding the prior authorization process are released.
Questions regarding this issue may be directed to Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org