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The majority of prior authorization nightmare stories center around patients not being able to receive needed medication, whether for new prescription or because of a change in insurer rules. But medication is not the only thing physicians must submit prior approvals for. Dr. Pierre Manzo recently told the story of a patient trying to replace his CPAP machine because it was falling apart. His insurer wanted him to undergo a sleep study, since it had been several years since he’d participated in one. The situation went rapidly downhill from there: the insurer approved a home sleep study, the patient did the study with his CPAP on, so the study came back normal, and the insurer wouldn’t cover new supplies since he “didn’t have sleep apnea.”

After weeks of phone calls, the insurer agreed to pay for a new sleep study to prove the diagnosis, and new equipment was approved. We’ll likely be hearing more of these stories, with CMS adding to its list of durable medical equipment that’s subject to prior authorization and payers following suit. In 2016, CMS created a master list of DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies) that may become subject to prior authorization. At that time, CMS said it would publish a list of required prior authorizations 60 days before implementation. In December 2016, CMS began requiring prior authorization for power wheelchairs in four states, with the intention of expanding those requirements nationwide. As of September 1 of this year, there will be 31 items on the list, all variations on power wheelchair configurations. The process is, unsurprisingly, somewhat cumbersome, with an initial prior authorization determination being made by CMS or its contractors within 10 business days and resubmitted request processed within 20 days.

As an example, the Massachusetts Health and Human Services Division says a lack of prior authorization is one of the top four reason for DME claim denial. The Mass HHS website suggests referring to its online guideline for payment and coverage for a list of codes requiring prior authorization.

Dr. Manzo sums things up concisely in his post relating his frustration with prior authorization: “I understand part of the insurance companies’ strategy is that if there are enough hurdles to jump over—or if the hurdles are too high—some of us might stop running. However, as advocates for our patients, we do the best we can.”

Specifically, he advises physicians to remember that “the process can be less frustrating when you and your staff work as a team to minimize prior authorizations or make them easier to complete through good documentation and communication with your team.”


“Prior Authorization Equals Current Frustration: Challenges in Practice,” MedicalBag.com, February 7, 2018

“CMS to Require Prior Authorization for Certain Durable Medical Equipment,” FPM, January 5, 2016

“CMS Expands Prior Authorization for DME,” Getting Paid Blog, July 3, 2017

“Prior Authorization Process for Certain DMEPOS Items,” CMS.gov, June 1, 2018

“Medicare Program; Update to the Required Prior Authorization List of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items That Require Prior Authorization as a Condition of Payment,” Federal Register, June 5, 2018

“Final Rule Confirms Certain Items Will Require Prior Authorization,” AAFP News, January 3, 2016

Last Updated on November 22, 2022

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