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Prior Authorization for DMEPOS

Your voice matters!

Prior authorization helps DMEPOS suppliers make sure they meet Medicare coverage, payment, and coding rules before they deliver the items. The DME MAC will review the medical documentation and send an affirmed or non-affirmed decision. See the Supplier Manual Chapter 9 – Coverage and Medical PolicyPDF for more information and background about the program.

Prior Authorization Process for DMEPOS Items

Fee-for-Service Medicare requires prior authorization for these HCPCS codes filed to DME MACs:

Program HCPCS Codes When to expect a decision*: Decision is valid for:
Lower Limb Prostheses (LLP) L5856, L5857, L5858, L5973, L5980, L5987 10 business days 120 calendar days
Orthoses L0648, L0650, L1832, *L1833, L1851

Effective August 12, 2024: L0631, L0637, L0639, L1843, L1845, L1951

*L1833 removed from list effective August 12, 2024
5 business days 60 calendar days
Osteogenesis Stimulators Effective August 12, 2024, for CA, FL, OH, and PA: E0747, E0748, E0760

Effective November 12, 2024, for all remaining states and territories
5 business days 60 days
Power Mobility Devices (PMD) K0800-K0802, K0806-K0808, K0813-K0829, K0835-K0843, K0848-K0864

You may voluntarily include these accessories with the request for the power wheelchair base K0800-K0802 K0813-K0829, K0835-K0843, K0848-K0864:

E0950, E0955, E1002-E1010, E1012, E1029, E1030, E2310-E2313, E2321-E2330, E2351, E2373, E2377, E2601-E2608, E2611-E2616, E2620-E2625, K0020, and K0195
10 business days 6 months
Pressure Reducing Support Surfaces (PRSS) E0193, E0277, E0371, E0372, E0373 5 business days 1 month

*Expedited requests: If there is a valid need for an expedited review, we will make reasonable efforts to send a decision within 2 days.

How to Send Your Request

Affirmed & Non-Affirmed Decisions

Affirmed decisions are valid for a certain length of time, depending on the category. When the prior authorization is affirmed, the supplier must deliver the item within the listed timeframe (see table above). If the item is not delivered within the time limit, the supplier will need to send another request.

We will send decision letters to the supplier and the beneficiary. You may also request a copy of the letter to be sent to the physician.

The letter will include the Unique Tracking Number (UTN). The decision and UTN stays with the beneficiary. A supplier may transfer the UTN to another supplier per privacy laws.

Add the UTN to Your 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.

Information about other Pre-Claim Review Programs:

CGS Education & Tools

CMS Information

See the Prior Authorization Process for Certain DMEPOS ItemsExternal Website page for CMS-developed presentations, Medicare Learning Network materials, and other support materials including:

Attention: If you are looking for information about Hospital Outpatient Department Prior Authorization or Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT), please visit your A/B MAC websiteExternal Website.

Prior Authorization Education

Prior Authorization

See the DME Provider Outreach & Education: Calendar of Events for upcoming webinars and events related to required prior authorization.

Prior Authorization Education Smart Submission

Revised 07.16.24

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