Prior Auth & Competitive Bidding
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Medicare, as with other third-party payers, has had to contend with an explosion of reimbursements associated with an increase in utilization of a wide variety of medical/surgical services. To reduce reimbursement, Medicare has been expanding the number of AFO devices requiring prior approval.
Since August 2024, Medicare has had L1951: on its prior authorization listing.
L1951 Ankle foot orthosis (AFO), spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment
More recently, in mid-April 2026, Medicare added L1932 to its prior authorization list:
L1932: Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
Both L1932 and L1951 devices are prefabricated and require custom fitting at the time of delivery. Both also have prefabricated off-the shelf versions L1933 or L1952. Due to a quirky rule in the Medicare fee schedule, the reimbursement is the same for both the off-the-shelf and custom fit versions. The off-the -shelf versions also do not require prior authorization
Medicare will not pay any additional fee for your labor in custom fitting. So you may ask then why bother to bill for the custom fit code when you will be required to go through a labor-intensive fitting and prior authorization process for the custom fit version?
The answer goes to the looming question of competitive bidding. Before that is explained, let’s go back to the prior authorization process. Prior authorization can easily be accomplished on either Noridian (JA or JD) or myCGS (JB JC) provider portals, depending on the patient’s permanent address. One can upload the patient’s demographics and chart notes and within a few business days, if approved, the DME MAC will issue you a Unique Tracking Number (UTN). This number stays with the patient and is good for several months. Unfortunately, if the patient decides to change suppliers, you may lose a patient to another supplier, but you may also gain other patients who wish to transfer from another supplier.
Once ready for claim submission, the UTN can be electronically submitted to the appropriate DME MAC.
Recent statistics illustrate that at least 75% or more of AFO prior authorizations are affirmed in favor of the provider.
As for competitive bidding, this is a process which has not touched ankle foot orthotic products just yet. The next round of competitive bidding is slated to start in 2028, with bids to be accepted sometime later this year and into 2027. The goal of this program is to reduce the number of suppliers providing an off-the-shelf products and limit those to the lowest bidders. Typically competitive bid products would be shipped from one supplier.
In previous rounds of competitive bidding, reimbursement for certain spinal (back) braces was reduced by 70% or more. Hence many providers may want to seek refuge in custom fit or custom fabricated devices, because although these types of devices require skilled personnel for fitting, they are exempt from competitive bidding. One should take solace that at the current time, no ankle foot codes are on the competitive bid listing for 2028 to 2029 or beyond. So where does that leave us?
For those who chose to provide L1932 or L1951 or any other device requiring prior authorization, Medicare is offering a gold key. That is if 90% of your prior authorizations for a specific code are accepted (subject to certain utilization thresholds), then your practice would be exempt from prior authorization. But it is Medicare who selects those who can opt out of this prior authorization process
Like everything else, there are pros and cons to this.
Many providers do not want to opt out of the prior authorization process, because obtaining prior authorization almost always guarantees exemption from other audits on those claims. Opting out of prior authorization means you don’t have the hassle of submitting prior authorizations for a specific HCPCS code, but, the con, is that you would be possibly the target of an audit for that code. Providers eligible to elect to opt-out of this process should have received communication from their DME MAC sometime in April 2026. If you are selected to opt out of the prior authorization process and want to continue to submit prior authorizations, you must notify Medicare by May 26, 2026.
For more information on the opt-out program see your DME MAC Website.
If the patient truly requires custom fitting, then provide those custom fitting services. If not, provide the off-the-shelf version. Wholesale switching to one category of device or another, may certainly catch the “eye” of a computer algorithm at the DME MAC. If choosing a custom fit device, provide what is medically necessary for the patient and document the custom fitting services provided at the time of delivery. Beware that failure to document custom fitting at the time of delivery, will result in denial of the entirety of the claim.
As always, KevinRoot Medical is available to help connect you with experienced professionals who can assist with all of your enrollment needs, while also supporting practices with premium Root orthotics, custom solutions, and advanced lower-extremity biomechanical technologies designed for today’s modern podiatric practice.
