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CMS Finalizes Prior Authorization Rule for General DME

Article Source: MiraVista, LLC

CMS finalized the rule to implement Prior Authorization for general DMEPOS items. The final rule was published on December 29th. The proposed rule, published in May 2014, suggested that a prior authorization requirement be imposed for selected HCPCS that are frequently subject to unnecessary utilization.  The originally proposed master list consisted of 139 HCPCS.  In the final rule, CMS indicates that a smaller list, referred to as the Required Prior Authorization list, will be released within 60 days of the final rule. So we expect to see the official list of HCPCS subject to this ruling by the end of February 2016.

The master list is already provided in the final notice and includes common products such as the E0601 (CPAP), E0260 (semi-electric hospital bed), E0277 (group 2 support surface), K0004 (manual wheelchair), multiple power wheelchair codes, multiple lower limb prosthesis codes and more. As a surprise update, CMS opted to remove five lower limb HCPCS that were included in the proposed rule but decided to add the E1390 oxygen concentrator. 

Furthermore, the final rule also includes the proposed provision to apply this prior authorization requirement to competitive bidding areas. This means that contracted suppliers will not be exempt from this protocol.

As an industry we have seen many successful accounts of suppliers operating in prior authorization demonstration areas for power mobility devices (PMDs).  This new opportunity to expand prior authorization will alleviate burdens faced by suppliers that continually struggle with denials and audits. MiraVista is working through the content of this final rule, and will publish more details in the days ahead.

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