For Medicare DME suppliers
Prior authorization starts on 28 October for four more orthosis codes, a support surface and a manual wheelchair base.
Send us the request before you submit it. We read the order, the face-to-face note and the evaluation against the coverage policy for that item, and tell you what is missing and who has to supply it before the DME MAC does.
What Medicare changes on 28 October, and what its data shows
- 28 October 2026: prior authorization becomes a condition of payment nationwide for four orthoses codes, one pressure reducing support surface and one manual wheelchair base. Two upper limb orthoses follow in three phases, starting with California, Florida, Michigan and New York. CMS, update of 29 July 2026.
- 72.9% of completed DMEPOS prior authorization requests were provisionally affirmed in fiscal year 2024. CMS program statistics, FY2024.
- 1,165 of the 94,401 denied claims in that program were appealed, and 38.4% of those were overturned at the first level. CMS gives the most common reason: the appeal added documentation that was missing from the first review. Source: the same CMS statistics.
- 90%: a supplier with a provisional affirmation rate of 90% or higher may qualify for exemption from prior authorization. CMS-1828-F, 2 December 2025.
How it works
- Send the request before you submit it: the standard written order, the face-to-face note and, for a wheelchair, the specialty evaluation.
- We check it against the Local Coverage Determination for that item. Each coverage criterion, the order elements, the timing of the face-to-face encounter, and whether the notes give measurements where the policy needs them. You get back what the reviewer will look for, what is missing, who has to supply it, and the request assembled from the records you already have.
- You submit through your DME MAC portal. The decision goes on the record, affirmed or not, with the reason. If it is not affirmed, we prepare the resubmission from what the reviewer asked for.
Who we work with
Accredited suppliers enrolled in Medicare. Before we start, we check the supplier against the HHS-OIG exclusion list. Every statement in a request comes from the prescriber's or the therapist's record, quoted with its date, and every request and decision sits on a record you can show an auditor.
Start with five, free
Send up to five recent requests or non-affirmation letters with the patient identifiers removed. We check each against its coverage policy and show you what the reviewer would have asked for. After that, each request is $39, with no monthly minimum.