Lower Limb Prostheses Required Prior Authorization
CMS requires prior authorization of these six lower limb prostheses (LLP) HCPCS codes for all states and territories:
L5856, L5857, L5858, L5973, L5980, and L5987 (functional level 3 or above)
We will base the prior authorization decision on coverage criteria found in the Local Coverage Determination (LCD) L33787
and related Policy Article A52496.
Submit a Prior Authorization Request by either:
- DME myCGS portal – the fastest, easiest way to send prior authorization requests and check the status.
- Mail, Fax, or esMD using the Prior Authorization (PA) Submission Form/Coversheet
. For esMD submissions, use the document/content type "8.4".
What Suppliers Need to Know
What are the timelines for a prior authorization request?
The DME MACs will complete their review and send a detailed decision letter by the 10th business day following receipt of an initial or resubmitted request.
Expedited Requests: If the DME MAC substantiates the need for an expedited decision, the DME MAC will make reasonable efforts to communicate a decision within two business days of receipt of the expedited request. Suppliers should use fax, esMD, or myCGS for expedited requests.
How long is the decision valid?
Prior authorization decisions for LLP codes will remain valid for 120 calendar days following the provisional affirmation review decision.
What if the beneficiary needs two items (for example, a foot and knee) that require prior authorization? How are two UTNs submitted on one claim?
You may submit one Prior Authorization request for both codes. However, we will issue two separate UTNs and two response letters, one for each code. Enter each UTN on the electronic claim 2400 - Service Line for the applicable HCPCs code.
Where do we enter the Unique Tracking Number (UTN) on the 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.
Are there any exceptions to the Prior Authorization process?
The following claim types are excluded from lower limb prostheses prior authorization:
- Veterans Affairs
- Indian Health Services
- Medicare Advantage
- Part A and Part B Demonstrations
How to we check the status of a prior authorization request?
Check the status of your prior authorization in myCGS in the "Claim Preparation" Tab under "Prior Authorization".
Resources
- Dear Physician Letter – Artificial Limbs and Braces (O&P)
- Lower Limb Prostheses Documentation Checklist
- Online Education Course: Condition of Payment Prior Authorization (PA) Program
- Prior Authorization and Pre-Claim Review Initiatives
- Prior Authorization Operational Guide
- Prior Authorization (PA) Submission Form/Coversheet
- Prior Authorization Smart Submission - myCGS
- Prosthetic Feet and Additions to Lower Limb Extremity Prostheses – Correct Coding and Coding Verification Review Requirement
- Reasons for Non-Affirmed Prior Authorization for Lower Limb Prostheses
Updated: 02.21.24
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