CMS finalizes prior authorization rule for certain medical equipment, supplies

The Centers for Medicare & Medicaid Services last week issued a final rule establishing a prior authorization process for certain durable medical equipment, prosthetics, orthotics and supplies that are “frequently subject to unnecessary utilization.” According to CMS, the process will not create new clinical documentation requirements, but will try to ensure that existing documentation, coverage and coding requirements are met before items are furnished to beneficiaries and claims submitted for payment. The rule creates a Master List of 135 DMEPOS items that are potentially subject to prior authorization because they have an average purchase fee of at least $1,000 or an average rental fee schedule of at least $100, and have been the subject of certain reports by the Department of Health and Human Services Office of the Inspector General, Government Accountability Office or Comprehensive Error Rate Testing Program. However, only some of the items will require prior authorization. The Required Prior Authorization List will be published in the Federal Register 60 days prior to implementation. Medicare or its review contractor will “make a reasonable effort” to render an initial determination on prior authorization requests within 10 business days, and provide an expedited review process when the standard timeframe would seriously jeopardize the patient’s life or health, CMS said. The agency plans to issue specific prior authorization guidance.