Medicare Expands Prior Authorization to Six Lower Limb Prosthetic Codes

February 20, 2020

On February 11, 2020, the Centers for Medicare & Medicaid Services (CMS) announced that six lower limb prosthetic Healthcare Common Procedure Coding System (HCPCS) codes will be subject to prior authorization as a Medicare condition of payment. The six HCPCS codes cover certain lower limb microprocessor components and prosthetic feet [HCPCS codes:  L5856, L5857, L5858, L5973, L5980, L5987]. Because prior authorization is new for lower limb prostheses, CMS will phase it in for these codes in only four states, effective May 11, 2020 – Texas, Pennsylvania, Michigan, and California. The new policy will go into effect nationwide beginning on October 8, 2020.  

Once this new requirement goes into effect, physiatrists should expect that prosthetists with whom they work may require additional documentation for Medicare patients earlier in the process of treating patients than usual. All claims associated with the six identified HCPCS codes that do not have provisionally affirmed prior authorization will be denied payment. In order to continue to provide patient care without delay or interruption, it is important that required documentation associated with the prior authorization process is completed in a timely fashion.

CMS is expected to issue additional guidance regarding its deadlines to respond to prior authorization requests for these prosthetic codes in the coming months. AAPM&R will continue to monitor any further expansion of prior authorization and any related impact on patients and physiatrists.