Prior Authorization of Power Mobility Devices (PMDs) Demonstration

The Prior Authorization of Power Mobility Devices (PMDs) Demonstration will end as scheduled on August 31, 2018. Beginning nationwide on September 1, 2018, CMS is adding 31 items currently included in the PMD Demonstration to the Required Prior Authorization List (PDF). All new rental series claims for these items with a date of service on or after September 1, 2018, must be associated with a prior authorization request as a condition of payment.

In the 19 states currently participating in the PMD Demonstration, DME MACs will continue accepting prior authorization requests for the PMDs being added to the Required Prior Authorization List without interruption. CMS will cease accepting prior authorization requests for the following items under the PMD Demonstration that are not being added to the Required Prior Authorization List on August 18, 2018: K0800, K0801, K0802, K0812, K0890, K0891, and K0898.

Prior authorization decisions received prior to September 1, 2018 under the PMD Demonstration will continue to be valid and will satisfy the condition of payment requirement.

Please click here for more information on the prior authorization process for items on the Required Prior Authorization List.

Updated: January 23, 2017

The Prior Authorization of Power Mobility Devices (PMDs) Demonstration has been extended for 3 years. The demonstration will now end on August 31, 2018 for all 19 states. The original demonstration requirements remain the same for all states.

CMS originally announced the Prior Authorization of Power Mobility Devices Demonstration on November 15, 2011, but in response to public comments, CMS delayed the demonstration start date to September 1, 2012 to make necessary improvements. The demonstration began for orders written on or after September 1, 2012 and was originally scheduled to end on August 31, 2015.  Due to a recent CMS extension, the demonstration is now scheduled to end on August 31, 2018. This demonstration is designed to develop and demonstrate improved methods for the investigation and prosecution of fraud in the provision of care or services under the health programs established by the Social Security Act. This demonstration will also lead to reductions in improper payments for PMDs, which will help ensure the sustainability of the Medicare Trust Funds and protect beneficiaries who depend upon the Medicare program.

Demonstration Description

The CMS implemented a Prior Authorization process for scooters and power wheelchairs for people with Fee-For-Service Medicare who reside in seven states with high populations of fraud- and error-prone providers (CA, IL, MI, NY, NC, FL and TX). In addition to the benefits mentioned above, this demonstration will help ensure that a beneficiary's medical condition warrants their medical equipment under existing coverage guidelines. Moreover, the program will assist in preserving a Medicare beneficiary's ability to receive quality products from accredited suppliers. For more information about the demonstration see "Fact Sheet: General Information" in the Downloads section below.

PMD Demonstration Evaluation

CMS has contracted with Provider Resources, Inc. (PRI) to conduct an evaluation of the Power Mobility Device (PMD) Prior Authorization Demonstration. An important part of this research is physician perspective and opinion. If you have prescribed a power wheelchair or a PMD for a Medicare beneficiary in the past, CMS is interested in your advice and opinion. Please share your opinions and thoughts with the PRI researchers. To schedule an interview with PRI, please contact (814) 806-3341 or PMD@provider-resources.com. Please see a letter from CMS related to this PMD evaluation in the download section below. 

Electronic Submission of Medical Documentation (esMD)

All Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) accept prior authorization requests through esMD. To submit a prior authorization request through esMD, providers and suppliers must choose a CMS-certified Health Information Handler (HIH) that offers prior authorization documentation submission services. To view a list of HIHs that offer this service, click the link called “HIHs that offer Prior Auth submission services” in the 'Related Links' section below.

Reason Statements for Denial

CMS and the DME MACs strive to provide detailed explanations for non-affirmative prior authorization decisions. CMS and the DME MACs have created a list of reason statements to provide a narrative explanation of the non-affirmative decision 'PMD PA Demo Reason Identifiers and Statements (June, 2013)' which are available in the Downloads section below.  

Demonstration Updates

July 15, 2015: The demonstration has been extended and will end on August 31, 2018 for all 19 states. The original demonstration requirements remain the same for all states.
July 29, 2014: Based on early successes, CMS is expanding the demonstration to 12 additional states (MD. NJ, PA, IN, KY, OH, GA, TN, LA, MO, WA, and AZ). This expanded demonstration begins on October 1, 2014. The demonstration will end on August 31, 2015 for all states. The original seven states are not affected by this expansion, and the original demonstration requirements remain the same for all 19 states.

Modifications Made After Initial November 15, 2011 Announcement

CMS received many comments on the Prior Authorization of PMDs demonstration after it was announced in 2011. CMS considered these comments carefully.

In response to comments received from stakeholders, CMS made a number of modifications to the Prior Authorization of PMD demonstration:

• CMS completed a separate Paperwork Reduction Act (PRA) notification for this demonstration and the Recovery Audit Prepayment Review demonstration. The demonstration was delayed until an OMB PRA control number was obtained.
• CMS removed the 100% Pre-Payment review phase (formerly Phase 1). All modifications that had previously been made to Phase 1 are no longer necessary or applicable as a result of the removal this phase.
• CMS now allows suppliers to perform the administrative function of submitting the prior authorization request on behalf of the physician/practitioner.
• CMS reduced the review time on resubmissions to 20 business days from 30.

For more information about these modifications see "Summary of Demonstration Modifications" in the ‘Downloads’ section below

Education and Outreach

CMS conducted extensive education and outreach before the demonstration to clarify all demonstration requirements to ordering physicians, practitioners, suppliers, and beneficiaries. CMS will continue to educate and engage the provider and supplier communities throughout the duration of the demonstration.

Helpful Educational Documents

• Physicians/Practitioners may find it helpful to review the Common Pitfalls document in the PMD documentation in the Downloads section below.
• Letters to physicians/practitioners/suppliers about the PMD demonstration are available in the Downloads section below.
• For more operational details about the demonstration please see the PMD Operational Demonstration Guide in the Downloads section below.

Please continue to check this web site for updated information.

If you have any questions regarding this demonstration please e-mail: PAdemo@cms.hhs.gov

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