[Federal Register Volume 87, Number 153 (Wednesday, August 10, 2022)]
[Rules and Regulations]
[Page 48609]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-17187]



[[Page 48609]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 410 and 414

[CMS-6087-N]


Medicare Program; Suspension of Required Prior Authorization for 
Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies 
(DMEPOS) Items Under Certain Circumstances

AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of 
Health and Human Services, (HHS).

ACTION: Suspension of prior authorization requirements for specified 
orthoses prescribed and furnished urgently or under special 
circumstances.

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SUMMARY: This document announces the suspension of prior authorization 
for specified orthoses items on the Required Prior Authorization List 
that require prior authorization as a condition of payment under 
certain circumstances when reported with certain modifiers. Items 
subject to face-to-face encounter and written order prior to delivery 
requirements are not impacted by this document.

DATES: The suspension of the prior authorization requirement discussed 
in this document took effect on April 13, 2022, when CMS published an 
announcement on its website.

FOR FURTHER INFORMATION CONTACT: Emily Calvert, (410) 786-4277.

SUPPLEMENTARY INFORMATION:

I. Background

    In the December 30, 2015, final rule (80 FR 81674) titled, 
``Medicare Program; Prior Authorization Process for Certain Durable 
Medical Equipment, Prosthetics, Orthotics, and Supplies,'' we 
implemented section 1834(a)(15) of the Act by establishing an initial 
Master List (called the Master List of Items Frequently Subject to 
Unnecessary Utilization) of certain DMEPOS that the Secretary 
determined, on the basis of prior payment experience, are frequently 
subject to unnecessary utilization and by establishing a prior 
authorization process for these items.
    In the November 8, 2019, Federal Register (84 FR 60648), we 
published a final rule titled, ``Medicare Program; End-Stage Renal 
Disease Prospective Payment System, Payment for Renal Dialysis Services 
Furnished to Individuals with Acute Kidney Injury, End-Stage Renal 
Disease Quality Incentive Program, Durable Medical Equipment, 
Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule Amounts, 
DMEPOS Competitive Bidding Program (CBP) Amendments, Standard Elements 
for a DMEPOS Order, and Master List of DMEPOS Items Potentially Subject 
to a Face-to-Face Encounter and Written Order Prior to Delivery and/or 
Prior Authorization Requirements.'' Through this November 2019 final 
rule, we harmonized the lists of DMEPOS items created by former rules 
and established one ``Master List of DMEPOS Items Potentially Subject 
to Face-To-Face Encounter and Written Orders Prior to Delivery and/or 
Prior Authorization Requirements'' (the ``Master List''). The November 
2019 final rule was effective January 1, 2020.
    In January 13, 2022, Federal Register (87 FR 2051), we published a 
document, titled, ``Medicare Program; Updates to Lists Related to 
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies 
(DMEPOS) Conditions of Payment.'' Through the January 2022 Federal 
Register document, we updated the Master List and selected certain 
lower limb orthoses, lumbar sacral orthoses, and power mobility devices 
to be subject to required prior authorization. The January 2022 Federal 
Register document was effective April 13, 2022.

II. Provisions of the Document

    In accordance with 42 CFR 414.234(f), CMS may suspend DMEPOS prior 
authorization requirement generally or for a particular item or items 
at any time and without undertaking rulemaking. Due to the need for 
certain patients to receive an orthoses item that may otherwise be 
subject to prior authorization when the 2-day expedited review would 
delay care and risk the health or life of the beneficiary, we are 
suspending prior authorization requirements indefinitely, under these 
limited circumstances:
     Claims for HCPCS codes L0648, L0650, L1832, L1833, and 
L1851 that are billed using modifier ST, indicating that the item was 
furnished urgently.
     Claims for HCPCS codes L0648, L0650, L1833, and L1851 
billed with modifiers KV, J5, or J4, by suppliers furnishing these 
items under a competitive bidding program exception (as described in 42 
CFR 414.404(b)), to convey that the DMEPOS item is needed immediately 
either because it is being furnished by a physician or treating 
practitioner during an office visit where the physician or treating 
practitioner determines that the brace is needed immediately due to 
medical necessity or because it is being furnished by an occupational 
therapist or physical therapist who determines that the brace needs to 
be furnished as part of a therapy session(s).
    Prior authorization will continue for these orthoses items (HCPCS 
L0648, L0650, L1832, L1833, and L1851) when furnished under 
circumstances not covered in this update, as well as all other items on 
the Required Prior Authorization List, available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/DMEPOS_PA_Required-Prior-Authorization-List.pdf.
    The Administrator of the Centers for Medicare & Medicaid Services 
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this 
document, authorizes Lynette Wilson, who is the Federal Register 
Liaison, to electronically sign this document for purposes of 
publication in the Federal Register.

    Dated: August 5, 2022.
Lynette Wilson,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2022-17187 Filed 8-9-22; 8:45 am]
BILLING CODE 4120-01-P