Phase 2 – Prior Authorization for Orthoses

Earlier this year, CMS began a prior authorization program for certain orthoses. Spinal Orthoses billed with HCPCS L0648 and L0650 plus Knee Orthoses billed with HCPCS L1832, L1833, and L1851 are now included in the prior authorization program. The program is being implemented in three phases, based upon geographic location.

• Phase 1 started on April 13, 2022, for patients in New York, Illinois, Florida, and California.
• Phase 2 starts on July 12, 2022, and after. Suppliers in Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington may begin the prior authorization process on June 28, 2022, for dates of service on July 12, 2022, or after.
• Phase 3 begins September 26, 2022, and will require all suppliers to use the process

Use the provider portals for the appropriate DME MAC to submit your prior authorization requests.

• For Jurisdiction A and D: Noridian Medicare Portal (NMP) - JD DME - Noridian
• For Jurisdiction B and C: myCGS Web Portal (cgsmedicare.com)

Documentation to include with the prior authorization request includes:

• Proof of a Face to Face encounter with the prescribing physician within six months
• A completed and signed Written Order Prior to Delivery (WOPD)
• Medical records justifying medical necessity of the brace

What Does This Mean for You?

After June 28, 2022, you may need to submit for prior authorization before you can dispense the brace. Learn more about the process, how to register on the site, and information about the required documentation here.