Orthoses Required Prior Authorization
Effective for dates of service on or after October 10, 2022, CMS requires prior authorization of these five orthoses HCPCS codes for all states and territories: L0648, L0650, L1832, L1833, and L1851.
A lack of a provisionally affirmed prior authorization request will result in a claim denial unless an exception applies.
Required Face-to-Face Encounter and Written Order Prior to Delivery (WOPD)
Effective for dates of service on or after April 13, 2022: CMS added HCPCS L0648, L0650, L1832, L1833, L1851 to the Required Face-to-Face Encounter and Written Order Prior to Delivery (WOPD) List (MLN Matters® Article SE20007).
Coding Verification
The DME MACs previously provided coding guidelines for these 5 L-codes in the local coverage determination related policy articles spinal orthoses (A52500) and knee orthoses (A52465). Code verification for the lumbar sacral orthoses (L0648 and L0650) became effective for claims with dates of service on or after July 1, 2010. The DME MACs issued a Coding Verification Requirement for L1832, L1833, and L1851 effective for claims with dates of service on or after 10/10/2022.
How to Submit a Prior Authorization Request
- DME myCGS portal – the fastest, easiest way to submit prior authorization requests and check the status.
- Mail, fax, and esMD – use the Prior Authorization (PA) Submission Form
Resources:
- Documentation Checklists
- Modifiers and Competitive Bidding Changes for Off-the-Shelf Back and Knee Braces Effective January 1, 2024
- Knee Orthoses Documentation of Knee Instability Reminder
- Providing Orthoses Prior to Surgery – Reminder
- Orthoses Prior Authorization – What Suppliers Need to Know
- Prior Authorization HCPCS Look-Up Tool
- Code Verification Review Requirement for Lower Limb Orthoses (L1832, L1833, and L1851) and Lumbar Sacral Orthoses (L0648 and L0650)
- Required Face-to-Face Encounter and Written Order Prior to Delivery (WOPD) List
- Reasons for Non-Affirmed Prior Authorization for Knee (L1832, L1833, L1851) and Spinal Orthoses (L0648 and L0650)
CMS Resources
- Prior Authorization Process for Certain DMEPOS Items FAQs
- Prior Authorization and Pre-Claim Review Initiatives
- Prior Authorization Process for DMEPOS – Operational Guide
Updated: 01.09.24