Prior Authorization and the New Lower Limb Prostheses LCD
We have received multiple questions about how the updated version of the Lower Limb Prostheses LCD that takes effect on September 1st affects Medicare's prior authorization program. In this post, we take a look at how the LCD and Medicare prior authorization interact with each other.
What You Need to Know
While the assumption that the updated Lower Limb Prostheses LCD might affect prior authorization is logical, neither the new LCD nor its associated Policy Article alters how Medicare's prior authorization program works.
Prior authorization for certain lower limb prosthetic claims began in 2020. The program is based on what gets delivered to Medicare beneficiaries as defined by particular L codes. Medicare currently requires O&P's to obtain prior authorization for 6 lower limb prosthetic L codes describing microprocessor-controlled knees and prosthetic feet: L5856, L5857, L5858, L5973, L5980, L5987.
In contrast, the updated Lower Limb Prostheses LCD taking effect on September 1st focuses on who can receive particular types of devices. The updated LCD for the first time gives Medicare K2 functional level individuals with a transfemoral amputation access to certain K3 knees and feet, including devices described by each of the above-listed L codes subject to prior authorization.
What this Means for You
Even though the LCD changes who can receive certain K3 components - K2 beneficiaries with a transfemoral amputation - it does not alter any aspect of the prior authorization program, which is based on what gets delivered to Medicare beneficiaries. If you are providing a K2 patient with a device described by any of the 6 L codes listed above, you must obtain prior authorization in exactly the same way as you currently do for K3 Medicare beneficiaries.
Be aware, however, that the coverage and documentation requirements for Medicare K2 transfemoral amputees have changed. You must satisfy them to obtain prior authorization if you are providing any device described by one of the 6 L codes listed above to a K2 beneficiary. For a detailed discussion of those new requirements, you can read our prior R&R post on the topic or read the updated LCD and Policy Article.