Medicare now requires prior authorization for several spinal and knee braces nationwide, along with two upper limb orthoses in four states.
CMS outlined the change in a July 30 Federal Register notice that added eight codes to its required prior authorization list: six orthoses, one manual wheelchair and one pressure-reducing support surface.
As of Oct. 28, prior authorization applies nationwide to a knee orthosis with adjustable joints (L1833) and three thoracic-lumbar-sacral orthoses (L0456, L0457 and L0486).
The requirement for an elbow orthosis (L3761) and a wrist-hand orthosis (L3916) is phasing in. It took effect Oct. 28 in New York, Michigan, Florida and California. The requirement will expand to Pennsylvania, Massachusetts, Ohio, Illinois, Texas, Georgia, Arizona and Oregon on Jan. 26, and remaining states and territories will follow April 26. CMS said the phased rollout lets it identify and address problems at smaller claim volumes before going nationwide.
CMS cited high improper payment rates for the braces. From 2023 to 2025, improper payment rates ranged from about 40% to 48% for upper limb orthoses and 35% to 47% for lower limb orthoses. Four of the newly selected orthosis codes — L0456, L0486, L1833 and L3916 — were first added to CMS’ master list because of aberrant billing. Payments for each rose more than 30% compared with the prior 12-month period, and CMS found no explanation for the increase, according to the notice.
Before providing one of the items and submitting a claim, the requester must submit a prior authorization request with the written order, relevant medical records and supplier documentation. CMS or a review contractor then provisionally affirms or non-affirms the request.
The same braces face a second documentation requirement. CMS added 22 codes, including the spinal, knee and upper limb orthoses and three ankle-foot orthoses, to the list of items that require a face-to-face encounter and a written order before delivery. The treating practitioner must see the patient within six months before the written order, and telehealth can be used when appropriate.
CMS estimates the prior authorization additions will save $15.8 million, net of implementation costs. The agency said it can suspend the program if it finds the process is creating barriers to care.
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