Prior Authorization and Medicare Updates + (EMPIRE EXCLUSIVE FEATURE)
Condition of Payment Prior Authorization (PA) Program
Prior Authorization for Lower Limb Prosthetic codes will be implemented in two phases. Phase one will begin September 01, 2020 in one state from each Durable Medical Equipment Medicare Administrative Contractor (DME MAC) jurisdiction: California, Michigan, Pennsylvania and Texas – Cigna Government Services (CGS) will begin accepting requests for prior authorization in Michigan and Texas on August 18, 2020. Phase two will begin December 01, 2020 and expands prior authorization to all remaining states and territories.
Effective January 1, 2021 any product billed with the listed L codes must be listed on the PDAC website. The program does NOT create any new documentation requirements; it simply requires the information be submitted earlier in the claims process.
Affected HCPCS Codes L5856: Addition to lower extremity prosthesis, endo knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type. L5857: Addition to lower extremity prosthesis, endo knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type. L5858: Addition to lower extremity prosthesis, endo knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type. L5973: Endo ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source. L5980: All lower extremity prostheses, flex foot system L5987: All lower extremity prosthesis, shank foot system with vertical loading pylon
Use the Empire L-Code search to filter by PDAC approved products
PDAC Filter
- Enter and select L-Code
- Check PDAC Only box
- Press Submit
- PDAC approved products are displayed with a green header
About Chris Empio
