Medicare DMEPOS Requiring Prior Authorization

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Prior authorization is a process through which a request for provisional affirmation of coverage is submitted to a medical review contractor for review before the item or service is furnished to the beneficiary and before the claim is submitted for processing. It is a process that permits the submitter/requester (for example, provider, supplier, beneficiary) to send in medical documentation, in advance of the item or service being rendered, and subsequently billed, in order to verify its eligibility for Medicare claim payment.

For any item or service to be covered by Medicare it must:

  • Be eligible for a defined Medicare benefit category
  • Be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member
  • Meet all other applicable Medicare coverage, coding and payment requirements

The following items require prior authorization:

  • K0856: Power wheelchair, group 3 std., single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
  • K0861: Power wheelchair, group 3 std., multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

Providers/suppliers should expect the prior authorization regulation to expand in the future for items that are considered frequently subject to unnecessary utilization.  For more information visit CMS.Gov.