CMS announced two Medicare policy updates affecting DMEPOS suppliers: One represents a long-sought step forward, but the other reinforces ongoing concerns about prior authorization expansion.
First, CMS announced that certain DMEPOS suppliers will be eligible for an exemption from prior authorization requirements. Under this policy, the DME Medicare Administrative Contractors (DME MACs) will review suppliers’ prior authorization approval rates. Suppliers with approval rates of 90 percent or higher will have the option to be exempt from submitting prior authorizations for the applicable year. To determine continued eligibility, DME MACs will conduct an annual post-payment medical review, and suppliers will be notified at least 60 days before an exemption period begins.
APMA views this as a positive development and a direct result of years of advocacy urging CMS to adopt a "gold carding" approach for providers who consistently demonstrate compliance and high approval rates. Rewarding proven performance with reduced administrative burden has long been a key APMA priority.
However, CMS also announced an expansion of prior authorization requirements. Beginning April 13, claims for HCPCS L1932 (ankle foot orthosis with a rigid anterior tibial section, total carbon fiber or equivalent material) submitted to a DME MAC will require prior authorization. Providers must ensure all documentation requirements are met, as outlined in the DME MAC AFO Local Coverage Determination (LCD) and the accompanying Policy Article.
APMA, alongside other medical societies, continues to advocate against any expansion of prior authorization in the Medicare program and will remain engaged with CMS to push for policies that reduce administrative burden while preserving timely access to medically necessary care.
Contact the APMA Advocacy Department with any questions at advocacy@apma.org.