HME COLUMN

Understanding the New Prior Authorization Codes

What recently added requirements change in your packet

By Nicholas Fortner

On Oct. 28, eight HCPCS codes joined Medicare's list of those requiring prior authorization. Five apply nationwide from that date: E0194, the air-fluidized bed; K0005, the ultralightweight manual wheelchair; L1833, the knee orthosis with adjustable joints; and the TLSO codes L0456, L0457 and L0486.

Two upper-limb orthosis codes, L3761 and L3916, phase in by state: New York, Michigan, Florida and California first, eight more states on January 26 and everywhere else on April 26.

The mechanics are the ones power wheelchair suppliers have lived with since the program began in 2017. A claim with a date of service on or after Oct. 28 needs a provisional affirmation first, or it will be denied. The durable medical equipment Medicare Administrative Contractor (MAC) answers a standard request in five business days and an expedited one in two.

What is new is who must build the packet. Six of the eight codes are orthoses, and many of the practices billing them have never submitted a prior authorization request.

Category by category, here is what the reviewer will look for that those packets have not had to contain.

K0005 is the base only.

The decision covers the wheelchair base; options, accessories and seating are not reviewed under it, and the MACs were to begin taking requests on Oct. 14. The document most packets will be missing is the specialty evaluation. The local coverage determination (LCD) requires one by a licensed or certified medical professional—usually a physical or occupational therapist—with no financial relationship to the supplier, and it requires the supplier to employ a RESNA-certified assistive technology professional who takes part in the selection.

The evaluation has to say why K0005's features (the adjustable axle, seat angle and camber) are needed and why a K0001 through K0004 base will not do. The face-to-face note establishes the mobility limitation; the evaluation justifies the chair. Both are needed.

L1833 is back, and it turns on an exam.

The code came off the list in August 2024 and returned on Oct. 28. The pathway most suppliers will use is instability—and the LCD and its policy article want two things in the treating practitioner's note: that the patient is ambulatory, and that joint laxity was tested and found. A diagnosis code for instability is not enough; the reviewer looks for the exam findings behind it.

The thoracic-lumbar-sacral orthosis (TLSO) codes indicate the reason for the brace and the type of brace.

L0456 is custom fitted, L0457 is off the shelf, L0486 is custom fabricated. The record needs a qualifying indication: a fracture, a post-surgical state, pain that limits function, or a weak or deformed spine. It also needs to support the type ordered: fitting modifications for custom fitted, the impression or model and the reason a prefabricated brace would not serve for custom fabricated.

E0194 has the longest paper trail.

An air-fluidized bed is the last step in the support-surface ladder, and the LCD expects the packet to show the steps before it: a Stage 3 or 4 pressure ulcer, at least a month of conservative treatment on a Group 2 surface with no progress toward healing, a comprehensive assessment by the treating practitioner, a trained adult caregiver in the home and the practitioner's judgment that the alternative is institutional care. Coverage is reassessed monthly, so the wound care notes are part of the packet.

Other Notes

The upper-limb codes follow the beneficiary's state and the date of service, not the supplier's location. A supplier in Arizona delivering to a California beneficiary will need the request starting Oct. 28; the same supplier delivering in Arizona will not until Jan. 26, 2027.

Two more things arrive with the same notice. All eight codes are also added to the list of items requiring a face-to-face encounter within six months before the order and a written order before delivery, so the encounter note and the order date now carry the claim where they did not before.

And beginning Oct. 15, a supplier newly enrolled in Medicare or one that changes ownership must obtain prior authorization on 40 additional codes for one year from its first claim for any of them. Most of those 40 are not on the required list; established suppliers bill them as they always have.

The advice is the same for every category: Read the LCD for the code you bill, list what it asks for and check the packet against the list before it goes to the MAC. A missing or misdated document is what sends most packets back.

Nicholas Fortner is the founder of AffirmDME, which makes prior authorization documentation software for Medicare DME suppliers. A free lookup of any HCPCS code's status by state, as well as requirement guides for each of the categories above, are at affirmdme.com/tools.