Prior Authorization Changes for Medicare Off-the-Shelf Knee and Back Braces

If you are involved with Medicare durable medical equipment (DME), you should be aware of some upcoming rule changes that may affect you in the next few months. 

These changes will require suppliers to obtain a prior authorization before dispensing and billing for a back or knee brace. These changes apply to suppliers and will also affect healthcare providers and patients. 

Overview of the Prior Authorization Requirement

In 2022, Medicare DME will be rolling out a new rule requiring all suppliers of orthopedic off-the-shelf knee and back braces to obtain prior authorization before dispensing and billing for a brace.

The requirement for prior authorization from suppliers will be rolled out in certain states in the U.S. according to the following timeline: 

• April 13, 2022: New York, Florida, Illinois, California 
• July 12, 2022: Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, Washington
• October 10, 2022: All other states and territories in the U.S.

For a list of HCPCS codes that will require a prior authorization, visit the Federal Registry here or this abbreviated PDF version from CMS here. 

Purpose of the Prior Authorization Requirement

The purpose of the prior authorization requirement, according to the Federal Registry, is to prevent fraud/scams, reduce waste, and protect access to care. This will be accomplished by ensuring that applicable coverage, payment, and coding rules are followed before the braces are delivered. 

For patients, this will ideally save money and prevent confusion, as patients will know if the brace will be covered by Medicare earlier in the payment process.

What Prior Authorization Means for Healthcare Providers?

Healthcare providers and clinics that supply off-the-shelf knee and back braces to patients will have to submit the prior authorization request and receive a decision before services are performed or items are provided to patients. 

The prior authorization request must include a written order/prescription, as well as relevant information from the patient medical record (diagnosis code, clinical notes from a face-to-face encounter within 6 months which support medical necessity), and supplier-produced documentation. Once the prior authorization request is received, a decision will be made and affirmation or non-affirmation (with reasons why) will be provided. For orthoses like knee and back braces, the decision will be made within five business days from receipt of the request.

If a prior authorization request is not submitted and affirmed prior to billing a claim, the claim will be denied payment.

With prior authorization, providers will know that the braces they order will be covered and paid for. However, there is a concern for time delays and access to care for patients, to which the Federal Registry documentation states: “If at any time we become aware that the prior authorization process is creating barriers to care, we can suspend the program.” For concerns or complaints about this program, be sure to contact 1-800-Medicare.

What Prior Authorization Means for Patients?

As a patient, know that there may be delays associated with receiving your knee or back brace. It is going to be extremely important to communicate with your doctor in order to receive the best treatment option for you in a timely and efficient manner. This includes advocating for yourself and describing your back pain or knee pain in detail and as early as possible to your doctor or healthcare provider.