The Centers for Medicare & Medicaid Services (CMS) issued a final rule December 29, 2015 that would require patients to obtain Prior Authorization for most lower limb prosthetics.
However, it may be a while before patients will need to obtain prior authorization before receiving prosthetic care. While the rule is in place beginning February 2016, we have some indications that: (1) CMS is more likely to take an incremental approach—regional steps with a limited number of devices seems more likely than a national rollout on all prosthetics; (2) CMS may be interested to see how the draft LCD follow-up proceeds before rolling out prosthetic Prior Authorization; (3) they pledge to take steps to avoid delay in patient access to care, and to try to minimize, if not eliminate the prospect that there are post-payment audits on medical necessity issues after a Prior Authorization has been secured, which could push the date for implementation of Prior Authorization for prosthetics 6 -12 months later.
While AOPA is still concerned that the prior authorization process will delay patient access to prosthetic devices, providers will have more time to prepare than initially expected, and should be able to comply with this new rule by the time it affects patients. Since prior authorization is premised explicitly on the need to control unnecessary or excessive utilization, clearly those classes of devices showing -40+% reduction in utilization since 2010 (K3 and K4 advanced prosthetics) should not be on the list of codes subject to prior authorization.