Product Name No Longer Required for Prior Authorization
February 26, 2021
As part of prior authorization for six O&P Healthcare Common Procedure Coding System (HCPCS) codes, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) had required that the products described by the codes be verified for correct coding by the Pricing, Data Analysis, and Coding Contractor (PDAC). The American Orthotic and Prosthetic Association (AOPA) announced that after its communication with the DME MAC Medical Directors (DMDs), the requirement has been overturned.
According to AOPA, the DME MACs were not issuing preliminary affirmation decisions without providers indicating the specific brand of prosthetic foot or knee they would deliver to the Medicare beneficiary. After explaining to the DMDs that flexibility in product selection is necessary for O&P providers to best meet patients' clinical needs, AOPA announced that it received the following response: "The DMDs understand that many variables can impact the selection of a specific brand-name product prior to delivery of the final prosthesis to a beneficiary. We do not prohibit substitution of another more suitable product, within the same HCPCS code that received provisional approval, at the time of delivery."
The DME MACs indicated to AOPA that, after consultation with the Centers for Medicare & Medicaid Services, it will be removing the requirement for inclusion of product selection information in prior authorization submissions.