In January 2022, the Centers for Medicare and Medicaid Services (CMS) announced the expansion of the Medicare prior authorization program to include the following five spinal and knee orthosis codes, L0648, L0650, L1832, L1833, and L1851.
While the existing Medicare prior authorization program for select lower limb prosthesis codes has been very successful to date, AOPA heard significant concerns from members regarding challenges that will occur 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 immediately engaged the DME MACs and high-level CMS officials regarding the negative impact Medicare 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, 2022, 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 a “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 the full guidance released by CMS.
As a reminder, Phase I of the expanded Medicare prior authorization program is in effect in New York, Illinois, Florida, and California for dates of service on or after April 13, 2022.