License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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June 20, 2024

Prior Authorization HCPCS Codes

CGS receives hundreds of requests each month for prior authorization on HCPCS codes that are not part of the prior authorization program. The table below lists the HCPCS codes that currently require prior authorization through Fee-For-Service Medicare.

LCD	HCPCS Codes
Lower Limb Prostheses	L5856, L5857, L5858, L5973, L5980, L5987
Orthoses (Knee and Spinal)	L0648, L0650, L1832, L1833**, L1851
Power Mobility Devices (PMD)	K0800-K0802, K0806-K0808, K0813-K0816, K0820-K0829, K0835-K0843, K0848-K0864
Power Mobility Devices (PMD) Accessories – Voluntary Authorization	E0950, E0955, E1002-E1010, E1012, E1029, E1030, E2310-E2313, E2321-E2330, E2351, E2373, E2377, E2601-E2608, E2611-E2616, E2620-E2625, K0020, and K0195
Pressure Reducing Support Services (PRSS)	E0193, E0277, E0371, E0372, E0373

CMS announced the addition of 12 HCPCS codes required for prior authorization beginning August 12, 2024:

LCD	HCPCS Codes
Orthoses (Knee and Spinal)	L0631, L0637, L0639, L1843, L1845, L1951
Osteogenesis Stimulators (Phase 1 on August 12, 2024, for California, Florida, Ohio, and Pennsylvania)	E0747, E0748, E0760
Osteogenesis Stimulators (Phase 2 on November 12, 2024, for remaining states and territories)	E0747, E0748, E0760

**Beginning August 12, 2024, CMS will no longer require prior authorization for L1833.

Prior Authorization Submissions

The easiest way to send a prior authorization request (PAR) to CGS is through the myCGS DME Web Portal. The Prior Authorization Smart Submission (PASS) application within myCGS allows you to take a step-by-step approach to sending your prior authorization. The PASS intuitive approach takes away extra work on your part by assuring you have reviewed everything when you send the documentation packet to CGS. Using the myCGS web portal is faster than simply faxing documents and you have knowledge CGS Medical Review received those pages.

If you are not sure if a specific HCPCS code is part of Medicare's Prior Authorization, use the Prior Authorization Lookup Tool

See the Prior Authorization for DMEPOS page for more information about submitting a prior authorization request.

Advance Determination of Medicare Coverage (ADMC)

Many of the PAR requests CGS receives are for wheelchair bases which are not part of prior authorization. For some of these bases, you are welcome to use ADMC for the HCPCS codes in the table below. ADMC is a voluntary program where suppliers send documentation via the myCGS web portal, esMD, fax or mail to be reviewed for medical necessity. Visit Advanced Determination of Medicare Coverage (ADMC) for more information.

HCPCS Code	Type of Wheelchair Base
E1161	Manual adult size wheelchair, includes tilt in space
E1231 – E1234	Manual pediatric size wheelchair, includes tilt in space
K0005	Manual adult size wheelchair, ultra lightweight
K0008	Custom manual wheelchair/base
K0009	Manual adult size wheelchair, not otherwise classified
K0013	Custom Motorized/Power Wheelchair Base
K0890 – K0891	Power pediatric size wheelchair, Group 5 – Single or Multiple power options

CGS Connect

If you have other HCPCS codes where you would like clinical guidance, the CGS Medical Review department offers CGS Connect®. This voluntary program gives you an opportunity to ask for a clinical review of pre-claim documentation. CGS clinicians will evaluate documentation and give guidance before you supply the DMEPOS item to the Medicare beneficiary. The complete list of HCPCS and information on how to submit documentation for review is listed here.

As you can see, CGS has a number of resources available to help you with reviews of documentation before sending a claim to CGS. Be sure to review these programs, the HCPCS codes associated with each one, and the respective submission instructions.