CMS Expands its Prior Authorization Program and Adds O&P Codes to the Master List of Codes Subject to Face to Face Encounters and Written Orders Prior to Delivery


On January 12, 2022, the Centers for Medicare and Medicaid Services (CMS) announced several updates to the Master List of DMEPOS items potentially subject to face-to-face encounter, written order prior to delivery, and prior authorization requirements. The Federal Register announcement (CMS-6081-N) added the following five O&P HCPCS codes to the Master List:
  • L0830 Halo Procedure, Cervical Halo Incorporated Into Milwaukee Type Orthosis
  • L1005 Tension Based Scoliosis Orthosis And Accessory Pads, Includes Fitting And Adjustment
  • L1906 Ankle Foot Orthosis, Multiligamentous Ankle Support, Prefabricated, Off-The-Shelf
  • L2580 Addition To Lower Extremity, Pelvic Control, Pelvic Sling
  • L2624 Addition To Lower Extremity, Pelvic Control, Hip Joint, Adjustable Flexion, Extension, Abduction Control, Each
  • L7368 Lithium Ion Battery Charger, Replacement Only
The following O&P code was removed the Master List:
  • L3761 Elbow Orthosis (EO), With Adjustable Position Locking Joint(s), Prefabricated, Off-The-Shelf
It is important to note that inclusion of a HCPCS code in the Master List does not mean that it is automatically subject to face-to-face encounter, written order prior to delivery, and prior authorization requirements; inclusion in the Master List only allows CMS to select the code for one or all these requirements in the future.
CMS-6081-N also announced that the following six O&P HCPCS codes will require a Face-to-Face Encounter and Written Order Prior to Delivery as a condition of payment for claims with a date of service on or after April 13, 2022:
  • L0648 Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
  • L0650 Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And Posterior Frame/Panel(S), Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Lateral Strength Provided By Rigid Lateral Frame/Panel(S), Produces Intracavitary Pressure To Reduce Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
  • L1832 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise
  • L1833 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf
  • L1851 Knee Orthosis (KO), Single Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off-The-Shelf
  • L3960 Shoulder Elbow Wrist Hand Orthosis, Abduction Positioning, Airplane Design, Prefabricated, Includes Fitting And Adjustment
Finally, CMS-6081-N added the following 5 O&P HCPCS codes to the list of codes that will require Medicare Prior Authorization:
  • L0648 Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
  • L0650 Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And Posterior Frame/Panel(S), Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Lateral Strength Provided By Rigid Lateral Frame/Panel(S), Produces Intracavitary Pressure To Reduce Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
  • L1832 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise
  • L1833 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf
  • L1851 Knee Orthosis (KO), Single Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off-The-Shelf
Medicare prior authorization for these five codes will be implemented in three phases. Phase 1 includes New York, Illinois, Florida, and California and begins on April 13, 2022. Phase 2 adds Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington and begins on July 12, 2022. Phase 3 includes all remaining states and territories and begins on October 10, 2022.
AOPA is performing an in-depth analysis of the expansion of these programs but some initial thoughts regarding the potential impact are below:
  • The five orthotic codes above represent expansion of Medicare prior authorization beyond the six lower limb prosthesis codes (L5856, L5857, L5858, L5973, L5980, and L5987) that have been subject to prior authorization since 2020.
  • The five codes that will require prior authorization as part of the new process (two spinal and three knee orthoses) are all codes that have high utilization patterns and have been identified as having high potential for fraud and abuse
  • Four of the five orthosis codes that are included in the expanded list of codes subject to prior authorization are included in the Medicare DMEPOS competitive bidding program.
  • A concern about subjecting the five orthosis codes to Medicare prior authorization is that these orthoses often are needed immediately to stabilize an injured and unstable spine or knee. Requiring prior authorization may be challenging due to the acute nature of treatment with these orthoses.
AOPA will work with CMS and the DME MACs to ensure a smooth transition of these HCPCS codes into the Medicare prior authorization program.
Questions regarding this issue may be directed to Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org .