Orthoses
CMS requires prior authorization of these five orthoses HCPCS codes for all states and territories:
- L0648, L0650, L1832, L1833, and L1851
- Changes effective August 12, 2024:
- L0631, L0637, L0639, L1843, L1845, L1951
- We began accepting prior authorization requests for these codes on July 29, 2024.
- L1833 – Removed from both Required Face-to-Face Encounter and WOPD and Required Prior Authorization lists effective August 12, 2024.
Note: CMS also updated the Required Face-to-Face Encounter and Written Order Prior to Delivery (WOPD) list. Use the Written Order Prior to Delivery (WOPD) Code Lookup to check your HCPCS code effective date.
We will base the prior authorization decision on coverage criteria found in these Local Coverage Determinations (LCDs) and related Policy Articles:
- Ankle-Foot/Knee-Ankle-Foot Orthosis LCD (L33686)
- Ankle-Foot/Knee-Ankle-Foot Orthosis Policy Article (A52457)
- Knee Orthoses LCD (L33318)
- Knee Orthoses – Policy Article (A52465)
- Spinal Orthoses: TLSO and LSO LCD (L33790)
- Spinal Orthoses: TLSO and LSO – Policy Article (A52500)
How to Send Your Request
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When to Expect the Decision We will send a detailed decision letter by the fifth business day following receipt of a request. Expedited requests: We will review the reason for the expedited request. If we decide there is a valid need for an expedited review, we will make reasonable efforts to send a decision within two business days. |
Deliver the Orthoses Within 60 Days
Prior authorization decisions for orthoses codes will remain valid for 60 calendar days following the affirmed review decision. For example: if the request is affirmed on April 30, the supplier has until June 28 to furnish the orthoses. Otherwise, the supplier must send a new request.
- 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 CMS Prior Authorization Process for Certain DMEPOS FAQs
and Prior Authorization Process for DMEPOS Operational Guide for more information.
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 L0631 (custom fitted) or L0648 (OTS). The supplier may list both HCPCS codes L0631 and L0648 on the request.
- A supplier lists a custom fit HCPCS code L0631 on the prior authorization request. However, substantial modifications are not needed at the time of the fitting, and OTS code L0648 is the correct code. The supplier should send a new prior authorization request for the OTS code L0648 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.
- Competitive Bidding Program Information
- Competitive Bidding Program (CBP) Modifiers Q&A
- Dear Physician Letters:
- Documentation Checklists:
- MLN SE20007: Standard Elements for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Orders Prior to Delivery and, or Prior Authorization Requirements
- Spinal Orthoses Provider Education Q&As
- The documentation does not include a valid face-to-face encounter within 6 months prior to the order.
- There is not a valid handwritten or electronic signature by the author of the medical record.
- The order was missing or incomplete.
- The medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knee.
- The medical record documentation does not show an objective description of joint laxity for knee instability. See Knee Orthoses Documentation of Knee Instability Reminder.
- The documentation shows the beneficiary needs the brace for post-operative recovery. Medicare expects the orthosis to be included in the Diagnostic Related Group (DRG) or Prospective Payment System (PPS) rates.
- The medical record documentation shows the beneficiary needs the orthoses during post-operative recovery; however, the surgery has not yet taken place. Do not send a Prior authorization before the surgery. If, after surgery, there is documentation of an emergent need for the orthoses, you may send an expedited request. If the beneficiary needs the orthosis sooner than two days, see instructions above. For more information about providing orthoses prior to surgery, see Providing Orthoses Prior to Surgery Reminder.
- Claims history shows same or similar equipment within the reasonable useful lifetime.
To resolve these errors, review the information published in the LCDs, policy articles, and Supplier Manual Chapter 3 – Supplier Documentation
Prior Authorization Education
See the DME Provider Outreach & Education: Calendar of Events for upcoming webinars and events related to required prior authorization.
Updated: 08.28.24
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