CMS establishes a DME prior authorization program

On Dec. 29, 2015, the Centers for Medicare & Medicaid Services (CMS) published a final rule establishing a prior authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization. The rule identifies continuous positive airway pressure (CPAP) devices as one of the items “potentially subject to prior authorization.”

The rule finalizes a previous CMS proposal for a prior authorization process, which was published in mid-2014. At that time the AASM submitted a letter to CMS arguing against such a process for sleep-related DME. The AASM’s position was that prior authorization would threaten beneficiaries’ ability to obtain timely treatment for a serious sleep illness.

The final rule creates a “Master List” of 135 high-cost DME items “frequently subject to unnecessary utilization.” Both CPAP and respiratory assist devices without backup rate (RAD) are included on the Master List. However, presence on the Master List will not automatically require prior authorization.

CMS indicates in the rule that it will initially implement prior authorization for a subset of select items from the Master List, which will be assigned to a separate “Required Prior Authorization List.” CMS will publish a notice in the Federal Register indicating which DMEPOS items will be subject to prior authorization 60 days before implementation.

The final rule goes on to explain that in order to obtain prior authorization, DMEPOS suppliers will be required to submit documentation indicating that the order meets all requirements outlined in Medicare policy. This will include documentation described in the relevant DMEPOS Local Coverage Determination (LCD). CMS indicates in the rule that efforts will be made to process prior authorization requests within 10 business days.

The AASM will notify members as soon as CMS publishes additional information indicating whether or not CPAP and RAD will be included on the Required Prior Authorization List.

2016-01-07T00:00:00+00:00January 7th, 2016|Clinical Resources, Professional Development|