CMS Expands its Prior Authorization Program

The Centers for Medicare and Medicaid Services (CMS) announced that three spinal orthoses (L0456, L0457 and L0486) and one knee orthoses (L1833) will require Prior Authorization nationwide for claims with a date of service on or after October 28, 2026.

In addition, CMS announced that two upper extremity orthoses (L3761and L3916) will require Prior Authorization but will be implemented in three phases.

  • Phase 1 will be for claims with a date of service on or after October 28, 2026, but only in these four states: California, Florida, New York and Michigan.
  • Phase 2 will be for claims with a date of service on or after January 26, 2027 in these eight states: Arkansas, Georgia, Illinois, Ohio, Massachusetts, Oregon, Pennsylvania and Texas.
  • Phase 3 will be for claims with a date of service on or after April 26, 2027, in all remaining states and territories.

This brings the total number of O&P codes requiring prior authorization to twenty-seven. You can view the complete Prior Authorization list here. To date, the Medicare Prior Authorization process has been a success and beneficial for the profession and patients. The addition of these codes may help to avoid unnecessary claim denials.

CMS Adds New O&P Codes Subject to Face-to-Face Encounters and Written Orders Prior to Delivery

CMS also announced that three spinal orthoses (L0456, L0457 and L0486), one knee orthoses (L1833), three ankle foot orthoses (L1906, L1933) and L1952), and two upper extremity orthoses (L3761 and L3916) 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 October 28, 2026.

This brings the total number of O&P codes requiring a Face-to-Face Encounter and Written Order Prior to Delivery to thirty-two. You can view the complete Face-to-Face Encounter and Written Order Prior to Delivery list here.

Medicare Expands the DMEPOS Master List

Finally, CMS announced that they were adding three new O&P codes (L1933, L1952 and L5827) to the Master List of DMEPOS Items Potentially Subject to Conditions of Payment such as Prior Authorization (PA), Written Orders Prior to Delivery (WOPD) and/or Face-to-Face Encounters (F2F) with a prescribing physician. It is important to remember that inclusion on the Master List does not mean that a F2F, WOPD or PA is required, it only means that the codes may be selected for either requirement in the future. You can view the complete Master List here.

For questions regarding any of these updates, please contact Joe McTernan at jmcternan@AOPAnet.org or Devon Bernard at dbernard@AOPAnet.org.