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

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Orthoses

CMS requires prior authorization of these five orthoses HCPCS codes for all states and territories:

L0648, L0650, L1832, L1833, and L1851

We will base the prior authorization decision on coverage criteria found in these Local Coverage Determinations (LCDs) and related Policy Articles:

How to Send Your Request

myCGS DME Web Portal with Prior Authorization Smart Submission (PASS) – The fastest, easiest way to send a request and check the status.
Prior Authorization Request Coversheet – Mail, fax, or esMD
Expedited: Send through the myCGS DME Web Portal or use the coversheet to fax or send through esMD.

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 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.

Beneficiary Needs the Orthosis Sooner Than Two Days

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 HCPCS codes L0648, L0650, L1832, L1833, and L1851. 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.

Orthoses Resources:

Top Reasons for Non-Affirmed Prior Authorization for Orthoses

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 survey, 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:

Updated: 06.18.24

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

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

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

Orthoses

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