In December of 2020, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) implemented Medicare prior authorization as a condition of claim payment for six lower limb prosthesis HCPCS codes (L5856, L5857, L5858, L5973, L5980, and L5987.) In addition to requiring prior authorization, effective for claims with dates of service on or after January 1, 2021, products described by the six codes above must be verified for correct coding by the Pricing, Data Analysis, and Coding Contractor (PDAC). So far, the Medicare prior authorization program has proven to be effective, efficient, and reasonable, with an average processing time of four business days for initial submissions, and a preliminary affirmation rate of higher than 50 percent for initial submissions and higher than 90 percent for resubmissions.
An issue that created concern among AOPA members was the inclusion of PDAC product verification as part of the Medicare prior authorization review process. 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.
AOPA engaged the DME MAC Medical Directors in very constructive and positive dialogue regarding the need for flexibility in product selection to best meet patients’ clinical needs. AOPA explained that while classification of a patient’s appropriate functional level often occurs during the early stages of clinical evaluation, the decision regarding the specific prosthetic components that best meet the patient’s clinical needs within their assigned functional level is often made toward the end of the treatment process. While AOPA did not challenge the concept of Medicare prior authorization, we respectfully requested the DME MACs reconsider the decision to require product selection as part of the process.
AOPA recently received a letter from the DME MAC Medical Directors in response to our concerns that, in part, stated the following:
“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.”
As a result of AOPA’s outreach, the DME MACs have indicated that, after consultation with the Centers for Medicare and Medicaid Services , they will be removing the requirement for inclusion of product selection information in prior authorization submissions.
AOPA is pleased by this development that will ensure continued flexibility for product selection within the Medicare prior authorization program and is encouraged by the willingness of the DME MACs to engage in constructive and effective communication with AOPA on important issues.