Effective mid-October 2026, CMS has mandated that the DME MAC add a more stringent prior authorization process for several HCPCS codes for new providers. This process is in addition to the existing prior authorization process and adds several codes that are not currently subject to prior authorization for existing providers. CMS has mandated these changes in order to stem the abuse of these codes by hit-and-run providers who bill for a significant number of units of these devices and then “run off with the money”.
For purposes of this prior authorization process, “new provider” is based on the provider’s PTAN. In addition to a first-time enrollment as a DMEPOS provider, newly designated “new providers” include:
—Those who have expanded and added an office location
—Practice is reactivated after enrollment revocation with a new PTAN
—You move your practice and they issue you a new PTAN
The list of HCPCS code is quite significant and impactful for “new” providers.
The probationary period will last for one year from the date of service for the specificDMEPOS.
HCPCS codes of particular interest subject to prior authorization for probationaryproviders, which are subject to this additional prior authorization requirement, include the following:
—Ankle-Foot/Knee-Ankle-Foot Orthoses: L1902, L1906, L1971, L4360, L4361, L4396, L4397
From the above list, the CAM boot AFO codes L4360/L4361 (pneumatic cam walker custom fit) or OTS and plantar fascial night braces L4396 and L4397 (custom fit and OTS), respectively, are especially impactful.
New suppliers who have not billed for the above DMEPOS prior to the mid-October startup of this initiative will have the added burden of obtaining prior authorization.
—Paul Kesselman, DPM