Medicare Pre Authorization for Certain Lower Limb Prostheses Codes

You and your staff need to familiarize yourself with this process and plan to submit preauthorization for any claims containing one or more of the following HCPCS codes:

• L5856
• L5857
• L5858
• L5973
• L5980
• L5987

Effective January 1, 2021, any product billed with these HCPCS codes must be listed on the PDAC website. Pre authorizations for these products submitted prior to January 1, 2020 will not require PDAC letters and will not be denied for lack of PDAC letters.

What does this mean for you?

• Pre Authorization will be required for dates of service on or after the effective date of Sept 1 or Dec 1, as appropriate for your state.
• The pre-authorization submission must include the SWO, medical records, and corroborating documentation.
• The DME MAC has 10 business days to review the request.
• Authorization letters will be sent to the mailing address on file with the NSC
• Once you receive authorization, you have 120 calendar days to provide the service.
• If the pre-authorization request is denied, you may resubmit
• You will receive a Unique Tracking Number (UTN) which must then be included on the submitted claim.

Register with your DME MAC to utilize the online pre-authorization submission:

• www.cgsmedicare.com  - Region B, Region C
• www.noridianmedicare.com  - Region A, Region D