Prior Authorization Program for Certain DMEPOS

3.10.1 - Prior Authorization Program for Certain DMEPOS (Rev. 937; Issued: 01-31-20; Effective: 03-02-20; Implementation: 03-02-20) A prior authorization program for certain DMEPOS items that are frequently subject to unnecessary utilization is described in 42 CFR §405 and §414.234. Among other things, these sections establish a Master List of certain DMEPOS items meeting inclusion criteria and potentially subject to prior authorization. CMS will select Healthcare Common Procedure Coding System (HCPCS) codes from the Prior Authorization Master List that shall require prior authorization, at its discretion. In selecting HCPCS codes, CMS may consider factors such as geographic location, item utilization or cost, system capabilities, emerging trends, vulnerabilities identified in official agency reports, or other analysis, and may implement prior authorization nationally or locally. The Prior Authorization Master List is the list of DMEPOS items that have been identified using the inclusion criteria described in 42 CFR 414.234. The Master List can be found on the CMS website. The Required Prior Authorization List is the items selected from the Prior Authorization Master List to be implemented in the Prior Authorization Program. The Required Prior Authorization List can be found on the CMS website, and will be updated as additional codes are selected for prior authorization. CMS may elect to exempt suppliers from prior authorization program upon demonstration of compliance with Medicare coverage, coding, and payment rules. The CMS may suspend prior authorization requirements generally or for a particular item or items at any time and without undertaking rulemaking. CMS provides notification of the suspension of the prior authorization requirements via—(i) Federal Register notice; and (ii) Posting on the CMS prior authorization Web site.