Skip to Main Content

Print | Bookmark | Email | Font Size: + |

Pressure Reducing Support Surfaces Prior Authorization

CMS requires prior authorization of these Group 2 Pressure Reducing Support Surfaces (PRSS) HCPCS codes: E0193, E0277, E0371, E0372, and E0373.

We will base the prior authorization decision on coverage criteria found in Local Coverage Determination (LCD) L33642External website and related Policy Article A52490External website.

How to Submit a Prior Authorization Request:

What Suppliers Need to Know

What are the timelines for a prior authorization request?

The DME MACs will complete their review and send a detailed decision letter by the fifth business day following receipt of an initial or resubmitted request.

Expedited Requests:

An expedited request should only be submitted if delays in receipt of a PA decision could jeopardize the life or health of the beneficiary.

One of the coverage criteria in LCD – Pressure Reducing Support Surfaces – Group 2 (L33642)External Website requires that the beneficiary has diagnosis of a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days. Patients with these conditions may meet the criteria for an expedited review.

If the DME MAC substantiates the need for an expedited decision, the DME MAC will make reasonable efforts to communicate a decision within two business days of receipt of the expedited request. Suppliers should use fax, esMD, or myCGS for expedited requests.

How long is the decision valid?

Prior authorization decisions for pressure reducing support surfaces codes will remain valid for one month following the "affirmed" review decision.

Same or Similar Equipment

We will check if the patient has previously received the same or similar piece of equipment and the item has not yet reached its reasonable useful lifetime period.

Where do we enter the Unique Tracking Number (UTN) on the claim?

Add the UTN in Item 23 of the CMS-1500 Claim Form. For electronic claims, add the UTN in either the 2300 – Claim Information loop or 2400 – Service Line loop in the Prior Authorization reference (REF) segment where REF01 = "G1" qualifier and REF02 = UTN.

Are there any exceptions to the Prior Authorization process?

The following claim types are excluded from lower limb prostheses prior authorization:

  • Veterans Affairs
  • Indian Health Services
  • Medicare Advantage
  • Part A and Part B Demonstrations
How to we check the status of a prior authorization request?

Check the status of your prior authorization in myCGS in the "Claim Preparation" Tab under "Prior Authorization".


Updated: 03.05.24


26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved