CHA News Article

CMS Issues Final Rule on Prior Authorization for DMEPOS Items

The Centers for Medicare & Medicaid Services has issued the attached final rule establishing a prior authorization program for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) that the agency believes are frequently subject to unnecessary utilization. The final rule defines unnecessary utilization and creates a new requirement that claims for certain DMEPOS items must have an associated provisional affirmed prior authorization decision as a condition of payment. This rule also adds the review contractor’s decision on prior authorization of coverage of DMEPOS items to the list of actions that are not initial determinations and, therefore, not appealable. The final rule is effective Feb. 29.