CMS has issued a proposed rule to establish a prior authorization process for certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) items that are frequently prescribed and used unnecessarily.
CMS developed a Master List of items, including 90 L-codes pertaining to lower limb prostheses and components, which are frequently subject to unnecessary utilization. CMS proposes to include an item on the initial Master List if the item appears on the DMEPOS fee schedule list, has an average purchase fee of $1,000 or more or an average rental fee schedule of $100 or more and meets one of these two criteria:
- The item has been identified in a Government Accountability Office (GAO) or Health and Human Services (HHS) Office of Inspector General (OIG) national report published in 2007 or later as having a high rate of fraud or unnecessary utilization;
- The item is listed in the 2011 or later Comprehensive Error Rate Testing (CERT) program’s Annual Medicare Fee-For-Service Improper Payment Rate Report DMS Service Specific Overpayment Rate Appendix.
The Master List would self-update annually and the items on the list would remain for 10 years. Items would only be removed from the Master List before 10 years when the Healthcare Common Procedure Coding System codes representing the item has been discontinued and “cross-walked” to an equivalent item or if the purchase price drops below the payment threshold. Items that have been on the Master List for 10 years may remain if a subsequent GAO, OIG or CERT DME Appendix report identifies the item to be frequently subject to unnecessary utilization.