The Centers for Medicare & Medicaid Services (CMS) is expanding the set of HCPCS codes subject to Medicare prior authorization.
Claims with dates of service of Oct. 28 or later will need to go through the prior authorization process if they include any of the eight newly include codes.
The July 30 edition of the Federal Register listed the affected HCPCS codes, as K0005 (ultralightweight manual wheelchair); E0194 (air fluidized bed); L1833 (knee orthosis, adjustable knee joints); L0456 (thoracic-lumbar-sacral orthosis, flexible, prefabricated item customized to fit a specific patient); L0457 (thoracic-lumbar-sacral orthosis, flexible, prefabricated, off the shelf); L0486 (thoracic-lumbar-sacral orthosis, triplanar control, includes carved plaster or CAD-CAM model, custom fabricated); L3761 (elbow orthosis); and L3916 (wrist hand orthosis).
CMS related the new prior authorization policies to its ongoing focus on reducing fraud.
“We believe prior authorization of these eight additional HCPCS codes will help further our program integrity goals of reducing fraud, waste and abuse, while also protecting access to care,” the Federal Register article said. “In addition, recent enforcement actions by the U.S. Department of Justice have continued to demonstrate broader program integrity risks, including fraudulent billing schemes involving medically unnecessary equipment, the submission of claims lacking documentation of medical necessity, and the use of telemarketing arrangements targeting Medicare beneficiaries.”
Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) codes that have been previously selected for prior authorization won’t be impacted.
“The remaining 74 HCPCS codes currently subject to the DMEPOS prior authorization requirement will continue uninterrupted,” the article said.
In a Sept. 3 announcement, the National Coalition for Assistive & Rehab Technology (NCART) said the DME MACs “will begin accepting prior authorization requests for K0005 CRT manual wheelchairs on Oct. 14, 2026. The DME MACs informed the provider community that [prior authorization] will be for the wheelchair base only and will not include a review of medical necessity for any options, accessories, seating or positioning items used with the wheelchair. However, wheelchair seat cushions (E2601-E2608 and E2622-E2625) and wheelchair back cushions (E2611-E2616 and E2620 and E2621) may be submitted voluntarily through the prior authorization process.”
