AOPA Participates in CMS Open Door Forum Call Regarding Medicare Prior Authorization for 6 Lower Limb Prosthesis HCPCS Codes


Yesterday, March 11, AOPA participated in a Medicare Open Door Forum call that provided sub-regulatory guidance on the upcoming implementation of Medicare prior authorization for six lower limb prosthesis HCPCS codes.  The call was hosted by the Centers for Medicare and Medicaid Services (CMS) and was led by Amy Cinquegrani and Dr. Scott Lawrence of the Medicare Division of Payment Methods and Strategies.  The four DME MAC Medical Directors also participated in the call and the question and answer period that followed it.  The presentation that was used as an outline was published in advance by CMS and may be accessed here. For additional information on Medicare prior authorization read AOPA’s initial announcement from February 11.

During the call, AOPA had the opportunity to request clarification regarding several issues that CMS had previously indicated would be addressed through sub-regulatory guidance.  New information received during the call included the following:

  • DME MACs will issue decisions on initial prior authorization requests within 10 business days of receipt of the request.
  • DME MACs will issue decisions on prior authorization resubmissions within 10 business days of receipt of the request (previous Medicare prior authorization programs allowed 20 business days for prior authorization resubmissions).
  • DME MACs will issue decisions on expedited prior authorization requests within two business days of receipt.  In order to be approved, an expedited request must show that the beneficiary’s life or health is in immediate danger.
  • Prior authorization requests may be submitted through multiple channels including electronic submission, submission through the DME MAC claim portal, by fax, and by mail.
  • For the four states (PA, MI, TX, CA) scheduled for implementation of prior authorization for dates of service on or after May 11, 2020, the DME MACs will begin accepting prior authorization requests on April 27, 2020.  For national implementation for dates of service on or after October 8, 2020, the DME MACs will begin accepting prior authorization requests on September 24, 2020.
  • HCPCS codes that receive provisional affirmation will not be subject to additional medical review except for random CERT review and UPIC (fraud and abuse) review.  This only applies to the six HCPCS codes subject to Medicare prior authorization.
  • DME MACs will provide education when prior authorization requests are denied, allowing providers to correct errors and facilitate re-submission.
  • CMS and DME MACs will closely monitor efforts to adhere to established timeframes for initial decisions and re-submissions.
  • Prior authorization requests will be subject to existing Medicare policy governing coverage of lower limb prostheses.  No changes are being made to the LCD or Policy Article as a result of prior authorization.

AOPA continues to be encouraged by the communication efforts of CMS and the DME MACs regarding the implementation of Medicare prior authorization.  While some uncertainty remains, AOPA is confident that Medicare prior authorization can be beneficial to Medicare beneficiaries, providers, and the Medicare program.

AOPA will continue to communicate information regarding Medicare prior authorization to our members and will be developing educational resources that will help AOPA members to better understand the program and contribute to its success.

Questions regarding Medicare prior authorization or the CMS Open Door Forum call may be directed to Joe McTernan at jmcternan@AOPAnet.org or Devon Bernard at dbernard@AOPAnet.org.