Certain L codes up for prior authorization

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Tuesday, February 11, 2020

ATLANTA – CMS plans to update the Federal Register today to add certain L codes to the prior authorization list for DMEPOS, according to the van Halem Group.

CMS will add the following codes to the list of items that require prior authorization as a condition of payment:

  • L5856 – (Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type)
  • L5857  – (Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type)
  • L5858 – (Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type)
  • L5973 – (Endoskeletal 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)


In phase one of the implementation on May 11, CMS will limit the prior authorization requirement to California, Michigan, Pennsylvania and Texas, one state in each of the four DME MAC jurisdictions.

In phase two on Oct. 8, CMS will expand the program to the remaining states in all four jurisdictions.

As part of the process, providers must submit prior authorization requests that include evidence that the item complies with all applicable Medicare coverage, coding and payment rules. Such evidence must include the order, relevant information from the beneficiary’s medical record and relevant supplier produced documentation. After receipt, CMS or one of its review contractors will conduct a medical review and communicate a decision that provisionally affirms or non-affirms the request.

CMS has previously added codes for power mobility and pressure reducing support surfaces to the prior authorization list.