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Orthoses Prior Authorization – What Suppliers Need to Know

Which orthoses codes are subject to prior authorization (PA)?

Spinal Orthoses – L0648 and L0650
Knee Orthoses – L1832, L1833, and L1851

When was PA required for these codes?

Prior authorization is required for these codes in all US states and Territories.

PA for orthoses was implemented in 3 phases:

Phase one April 13, 2022, in New York, Illinois, Florida, and California.
Phase two July 12, 2022, in Maryland, Pennsylvania, New Jersey Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington.
Phase three October 10, 2022, in all remaining states and territories not included in phase 1 or phase 2.

What are the delivery timeframes for L0648, L0650, L1832, L1833, and L1851?

Prior Authorization Request (PAR) decisions for these codes will remain valid for 60 days following the "affirmed" review decision. For example: if the PAR is affirmed on April 30, the supplier has until June 28 to furnish the orthoses. Otherwise, the supplier must submit a new PAR to restart the valid 60-day period.

Are there any exceptions to the PA process?

The following claim types are excluded from any PA program described in the CMS Prior Authorization Operational Guide, unless otherwise specified:

Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstrations

What if a beneficiary needs an item sooner than the 2-day expedited timeframe?

If the 2-day expedited review would delay care and risk the health or life of the beneficiary, CMS has suspended prior authorization requirements for HCPCS codes L0648, L0650, L1832, L1833, and L1851 furnished under these circumstances:

Claims for these HCPCS codes which meet the above description are to be billed using the ST modifier and will not undergo prior authorization. These claims will be subject to prepayment review.
For dates of service January 1, 2021 – December 31, 2023, suppliers furnishing these items under a competitive bidding program exception (as described in 42 CFR 414.404(b)), claims billed with modifiers KV, J5, or J4 would convey that the DMEPOS item is needed immediately. Claims submitted using the KV, J5, or J4 modifiers for HCPCS L0648, L0650, L1833, and L1851 will be subject to prepayment review.
Effective for dates of service on or after January 1, 2024, do not use the KV, J4, and J5 modifiers. If the beneficiary needs the item in an emergent situation, use the ST modifier or submit a prior authorization.

Were orthoses that were included in Round 2021 Competitive Bidding Program (CBP) (January 1, 2021 – December 31, 2023) subject to prior authorization?

Yes, HCPCS codes L0648, L0650, L1833, and L1851 that were included in the CBP are subject to PA requirements.

Refer to the DMEPOS Competitive Bidding Program Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists and DMEPOS Competitive Bidding Program Hospitals That are Not Contract Suppliers for additional information on competitive bidding exceptions.

Can prior authorization be submitted prior to surgery?

PA should not be requested prior to the start of medical necessity (e.g., before the surgery). If, after surgery, there is documentation of an emergent need for the orthoses, an expedited request may be submitted, or if an expedited request is not feasible, the ST modifier may be appended to the claim to bypass PA.

If the item is subject to a competitive bid exception, refer to the DMEPOS Competitive Bidding Program Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists and DMEPOS Competitive Bidding Program Hospitals That are Not Contract Suppliers or the above information.

Orthoses are subject to the hospital outpatient prospective payment system (OPPS) and Part A covered stays that are included in the Skilled Nursing Facility (SNF) and hospital Prospective Payment System (PPS) rate. Refer to the Claims Processing Manual (CMS Pub. 100-04), Chapter 20 to determine if an orthosis is adjunctive to another Part A claim.

Does CGS check for same/similar during the PA process?

Yes, CGS will check for same or similar items that appear in the beneficiary's claim history as of the date of the PA decision. Prior to dispensing an item, suppliers should confirm that the beneficiary has not received a same or similar item from another supplier.

Can Prior Authorization Requests (PARs) be submitted through myCGS?

Yes. The fastest, easiest way to submit a PAR is through the DME myCGS portal.

If you are not yet registered for myCGS, get started with the Registration Guide.
If you are already registered for myCGS, read the "Prior Authorization" section in the myCGS User Manual.

How do we check the status of a PA request?

Status is available in myCGS under the "Claim Preparation" section. Complete instructions are available in the myCGS User Manual. If your Prior Authorization request is submitted through the myCGS web portal, track your request within minutes of your submission.

What happens when an expedited PA request is submitted?

After the PA request is submitted, the medical records will be reviewed to confirm if the beneficiary's health/life is in jeopardy without the use of the orthotic device within the regular review timeframe (5 business days). For example, this might occur when a beneficiary suffers an acute/emergent injury to the knee or spine.

If the DME MAC substantiates the need for an expedited decision, the DME MAC will make reasonable efforts to communicate a decision (phone call and letter) within 2 business days of receipt of the expedited PA request. If the request is "affirmed," the supplier can then provide the item to the beneficiary and hold the claim until the Unique Tracking Number (UTN) is received.

If the need for an expedited decision is not substantiated, the DME MAC will respond in the 5 business day timeframe.

Where do we submit the Unique Tracking Number (UTN)?

For submission of a paper claim, the UTN should be in Item 23 of the CMS-1500 Claim Form.

For electronic claims, the UTN is submitted 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.

Can PA requests be submitted through Electronic Submission of Medical Documentation (esMD)?

Yes. When submitting through esMD, use the document/content type "8.4."

Revised: 12.18.23

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Orthoses Prior Authorization – What Suppliers Need to Know

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