Prior Authorization for Specific Orthoses

An announcement in the Federal Register regarding prior authorization for certain orthoses impacts our profession. Medicare announced the following products will require Prior Authorization, with the process being phased in over the year.

Orthoses billed with these HCPCS codes will require prior authorization:

• L0648 Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
• L0650 Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And Posterior Frame/Panel(S), Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Lateral Strength Provided By Rigid Lateral Frame/Panel(S), Produces Intracavitary Pressure To Reduce Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
• L1832 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise
• L1833 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The-Shelf
• L1851 Knee Orthosis (KO), Single Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off-The-Shelf

The effective dates for Prior Authorization are:

April 13, 2022, NY, IL, FL, CA

July 17,2022 MD, PA, NJ, MI, OH, KY, TX, NC GA, MO, AZ, WA

October 10, 2022, Nationwide

What Does This Mean for You?

Stay tuned for more details about prior authorization implementation. The DME MACs will be offering training and resources for suppliers.