Probationary Period of Prior Authorization for Certain Newly Enrolled DMEPOS Suppliers – Starting October 15, 2026
Effective October 15, 2026, the Centers for Medicare & Medicaid Services (CMS) will implement a nationwide, one-year probationary period for newly enrolled DMEPOS suppliers and suppliers undergoing qualifying changes of ownership.
Under the Probationary Prior Authorization (PPA) program, affected suppliers will be required to submit Prior Authorization Requests (PARs) for designated HCPCS codes in all states and U.S. territories.
Who Must Submit Prior Authorization Requests
This requirement applies only to:
- Newly enrolled DMEPOS suppliers; and
- Suppliers that undergo a 100 percent change of ownership.
Items Subject to Prior Authorization
The following HCPCS codes will require prior authorization under the probationary period:
- Osteogenesis Stimulators E0747,E0748
- Ankle-Foot and Knee-Ankle-Foot Orthoses L1902, L1906, L1971, L2035, L2132, L2134, L2136, L4360, L4361,L4396,L4397
- Knee Orthoses L1810,L1812,L1820,L1821
- Lower Limb Orthoses L1652, L1653,L1686,L1690
- Spinal Orthoses L0626, L0627,L0628,L0630,L0633,L0635,L0641,L0642,L0643,L0649,L0720
- Upper Limb Orthoses L3660,L3670,L3760,L3762,L3809,L3908,L3915,L3960
The DME MACs are expected to provide additional guidance and operational details as implementation approaches.
The addition of these items to the Probationary Prior Authorization program represents another important step in protecting the integrity and sustainability of the Medicare program. Historically, CMS and its program integrity contractors have identified patterns in which bad actors either establish new supplier entities and rapidly submit large volumes of claims or acquire existing supplier billing privileges and immediately begin billing for items that were either never provided or do not meet Medicare's reasonable and necessary requirements.
By requiring prior authorization during the probationary period, CMS is creating an additional safeguard designed to deter fraudulent billing activity, prevent improper payments, and strengthen oversight of newly participating suppliers. While the primary objective is to combat fraud, waste, and abuse, the program may also provide benefits to legitimate new suppliers by offering early feedback regarding documentation and coverage requirements, thereby helping ensure compliance from the outset.
Overall, we welcome this initiative as a meaningful enhancement to Medicare program integrity. For the vast majority of established suppliers, the operational impact should be minimal unless they enroll a new supplier entity or undergo a qualifying change of ownership. At the same time, the policy should help reduce opportunities for fraudulent activity and promote a more level playing field for compliant suppliers throughout the industry.
The PPA is only available to the suppliers who meet the aforementioned criteria. If other supplier submits the request for these items, they will be rejected as these items do not fall under the regular conditions of payment prior authorization.
If you have additional questions or concerns, please do not hesitate to reach out.