Probationary Prior Authorization (PPA) for Certain Newly Enrolled DMEPOS Suppliers – Starting October 15, 2026
Under the PPA, only certain suppliers are required to submit prior authorizations for select HCPCS codes.
Effective October 15, 2026, CMS is implementing a nationwide, one-year probationary period for newly enrolled DMEPOS suppliers and those undergoing changes of ownership.
Under this program, these suppliers must submit a Prior Authorization (PA) for specific HCPCS codes across all states and territories.
Who Must Submit Prior Authorizations?
This prior authorization requirement only applies to:
- Newly Enrolled Suppliers whose start date becomes active on or after October 15, 2026
- Suppliers that undergo a 100% change in ownership on or after October 15, 2026
Please note: The standard prior authorization program remains in effect and continues to apply to all suppliers.
Are Any New Suppliers Excluded from this Program?
Retail pharmacies and grocery stores are excluded from this program.
How Will I Know if I am Included in the Program?
Affected suppliers should expect to receive notification through enrollment-related communications, including notification letters and welcome packets from the National Provider Enrollment (NPE) contractors.
How Long Do New Suppliers Submit Prior Authorization Requests?
Under the PPA, new suppliers must submit prior authorization requests for one year from their start date. At the end of a one-year period, CGS will review your affirmation rate to decide what happens next.
HCPCS Codes Requiring Prior Authorization under PPA
For dates of service on or after October 15, 2026, suppliers who meet the above criteria must submit PA requests for the following:
| Program | HCPCS Codes | When to Expect a Decision | Decision is valid for: |
|---|---|---|---|
| Osteogenesis Stimulators | E0747, E0748 | 5 business days (not to exceed 7 calendar days) | 60 calendar days |
| Orthoses | Ankle-Foot/Knee-Ankle-Foot Orthoses: L1902, L1906, L1971, L2035, L2132, L2134, L2136, L4360, L4361, L4396, L4397 Knee Orthoses: L1810, L1812, L1820, L1821 Lower Limb Orthoses: L1652, L1653, L1686, L1690 Spinal Orthoses: L0626, L0627, L0628, L0630, L0633, L0635, L0641, L0642, L0643, L0649, L0720 Upper Limb Orthoses: L3660, L3670, L3760, L3762, L3809, L3908, L3915, L3960 |
5 business days (not to exceed 7 calendar days) | 60 calendar days |
We will base the prior authorization decision on coverage criteria found in the applicable Local Coverage Determinations (LCDs) and related Policy Articles. The resources below will help you with your submission.
Expedited Requests
If there is a valid need for an expedited review, we will make reasonable efforts to send a decision within 2 business days.
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. You may also request a copy of the letter to be sent to the beneficiary and/or the practitioner.
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.
Osteogenesis Stimulators Resources
Orthosis Resources
Beneficiary Needs the Orthosis Sooner than Two Days
If the two-day expedited review would delay care and risk the health or life of the beneficiary, CMS has suspended prior authorization requirements for orthoses HCPCS codes. Bill these claims using the ST modifier. The ST modifier is subject to prepayment review. See the Prior Authorization Process for DMEPOS Operational Guide
for more information.
Custom Fit and Off-the-Shelf Codes
When both the custom fit and the off-the-shelf (OTS) HCPCS code for the same product require prior authorization, you may list both codes on the prior authorization request.
If only the custom fit code or the OTS code is submitted for prior authorization, the decision will only apply to the code listed on the prior authorization request. The supplier will need to send a new request for the correct HCPCS code.
Examples:
Both the Custom Fit and Corresponding Off-the-Shelf Code Require Prior Authorization:
- The practitioner orders a brace that may be coded L0626 (custom fitted) or L0641 (OTS). The supplier may list both HCPCS codes L0626 and L0641 on the request.
- A supplier lists a custom fit HCPCS code L0626 on the prior authorization request. However, substantial modifications are not needed at the time of the fitting, and OTS code L0641 is the correct code. The supplier should send a new prior authorization request for the OTS code L0641 and deliver the item after receiving a UTN for the correct HCPCS code.
Only the Custom Fit or the Off-the-Shelf Code Requires Prior Authorization, Corresponding Code Does Not Require Prior Authorization:
When only the custom fit or off-the-shelf (OTS) HCPCS code requires prior authorization, only request prior authorization for the required code.
Additional Resources
- Dear Physician Letters:
- Documentation Checklists:
Posted: 09.17.2026
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