The Centers for Medicare & Medicaid Services (CMS) announced in January the expansion of the Medicare prior authorization program would include five spinal and knee orthosis codes: L-0648, L-0650, L-1832, L-1833, and L-1851. The American Orthotic & Prosthetic Association (AOPA) said it has heard “significant concerns” from members regarding challenges that will occur when obtaining Medicare prior authorization in situations where there is an immediate need to provide an orthosis to stabilize an injured or unstable spine or knee.
To address these concerns, AOPA said it has engaged Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and high-level CMS officials regarding the negative impact prior authorization for emergent-need orthoses would have when there was an immediate need for an orthosis, and suggested potential solutions to allow Medicare beneficiaries access while ensuring adequate protection of Medicare funds.
On April 12, CMS released guidance consistent with AOPA’s recommendations.
The CMS guidance stated that if the two-day expedited review process would delay care and risk the health or life of the beneficiary, the Medicare prior authorization requirement will be suspended. Claims for emergent-need orthoses that would otherwise require Medicare prior authorization must be submitted with an ST modifier. While the ST modifier will allow claims to be processed and paid, all claims submitted with the ST modifier will then be subject to pre-payment review.
View CMS’ full guidance on its website.
