AMARILLO, TX – The Centers for Medicare & Medicaid Services (CMS) published its annual Notice, updating the Master List of DMEPOS items potentially subject to prior authorization requirements (PAR) and the “Required” Prior Authorization list. The Master List serves as a library of DMEPOS items that CMS has identified as potentially vulnerable to fraud, waste, or improper payments. The inclusion of items on the master list does not impose new requirements, but it makes the item eligible to be selected for mandatory prior authorization requirements face‑to‑face (F2F) encounter, and written order prior to delivery (WOPD) requirements.

In this update, CMS added 18 HCPCS Codes to the Master List:

• A4238 – Supply allowance for adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service.
• A6214 – Foam dressing, wound cover, sterile, pad size more than 48 square inch., with any size adhesive border, each dressing.
• A6233 – Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size more than 48 square inch, each dressing.
• A6583 – Gradient compression wrap with adjustable straps, below knee, 30-50 mmhg, each.
• A6593 – Accessory for gradient compression garment or wrap with adjustable straps, not-otherwise specified.
• A7025 – High frequency chest wall oscillation system vest, replacement for use with patient owned equipment.
• E0468 – Home ventilator, dual-function respiratory device, also performs additional function of cough stimulation, includes all accessories, components and supplies for all functions.
• E0469 – Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device.
• E0691 – Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less.
• E0743 – External lower extremity nerve stimulator for restless legs syndrome, each.
• E0762 – Transcutaneous electrical joint stimulation device system, includes all accessories.
• E1399 – Durable medical equipment, miscellaneous.
• E2103 – Non-adjunctive, non-implanted continuous glucose monitor or receiver.
• E2377 – Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue.
• L1499 – Spinal orthosis, not otherwise specified.
• L2999 – Lower extremity orthoses, not otherwise specified.
• L5783 – Addition to lower extremity, user adjustable, mechanical, residual limb volume management system.
• L5841 – Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control.

CMS selected seven HCPCS codes from the Master List to add to the Required Prior Authorization List:

• L0651 – Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall.
• L1844 – Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated.
• L1846 – Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated.
• L1852 – Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial- lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf.
• L1932 – Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment.
• E0651 – Pneumatic compressor, segmental home model without calibrated gradient pressure.
• E0652 – Pneumatic compressor, segmental home model with calibrated gradient pressure.

In the Notice, CMS added a new exemption process, where CMS may elect to exempt a DMEPOS supplier from PA upon the supplier’s demonstration of compliance with Medicare coverage, coding, and payment rules.

The DME MACs will conduct an annual post-payment review to ensure compliance. CMS or its contractors would exempt providers that submitted at least 10 requests and achieved a PA provisional affirmation threshold of at least 90 percent during an annual assessment.

Suppliers who achieve a provisional affirmation rate of 90% or higher may qualify for exemption. Suppliers will have the option to opt out of the exemption. Should suppliers no longer meet the exemption criteria, a notice of withdrawal will be provided at least 60 days before the effective date. The exemption remains in effect until CMS elects to withdraw the exemption.

The calculation of compliance is based on the supplier’s PTAN number and jurisdiction. A DMEPOS supplier is required to reach eligibility for each PTAN and jurisdiction separately.

The DME MAC will notify suppliers of their exemption status by April 2, 2026. The first exemption cycle will begin on June 1, 2026, and will run annually thereafter. PARs received during an exemption period for exempt suppliers will be rejected. Suppliers who choose to opt out of the exemption program must submit the opt-out request to the DME MACs through fax, email, portal, or other electronic communication methods. Those who choose to opt out must do so no later than April 30, prior to the start of the annual exemption cycle.

Cara C. Bachenheimer, Esq., is an attorney with the Health Care Group at Brown & Fortunato, a law firm with a national health care practice based in Texas, where she heads up the firm’s Government Affairs Practice. Ms. Bachenheimer’s practice focuses on federal lobbying activities with Congress, the Administration, and federal regulatory agencies, such as CMS, FDA, IRS, and FAA. She can be reached at (806) 345-6321 or [email protected].

Jacque K. Steelman, Esq., is a member of the Health Care Group at Brown & Fortunato, PC, a law firm with a national healthcare practice based in Texas. She represents pharmacies, infusion companies, HME companies, manufacturers, and other healthcare providers throughout the United States. Ms. Steelman can be reached at (972) 684-5789 or [email protected].