No Affirmation, No Payment: Getting Prior Authorization Right Before the New O&P Codes Hit on October 28

• Intake and scheduling staff. The earlier a code is flagged, the more time the patient and your team have.
• Clinicians and fitters. Your evaluation notes become part of the packet, and they have to agree with the physician's record.
• Billers and RCM teams. A missing authorization or UTN means an automatic denial, not a correctable error.
• Fabrication and scheduling teams. Custom devices such as L0486 and backordered components can push delivery past the affirmation window.
• Referral sources. Physicians and NPs will be asked for complete, consistent documentation sooner, and turnaround matters.
• Multi-state groups. Elbow and wrist-hand orthoses phase in by state, so rules may differ between your locations for several months.
• Practices billing Medicare as secondary. Prior authorization is still required to bill Medicare.
• Newly enrolled suppliers and ownership changes. CMS also begins probationary prior authorization on October 15, 2026 for these suppliers.
• Patients. They are the ones waiting for a device, often after surgery or an injury.
  

Six orthotic codes are being added to the Required Prior Authorization List.

Required nationwide starting October 28, 2026: 

• L0456: TLSO, flexible, rigid posterior panel and soft anterior apron, prefabricated, custom-fitted
• L0457: TLSO, flexible, rigid posterior panel and soft anterior apron, prefabricated, off-the-shelf
• L0486: TLSO, triplanar control, two-piece rigid plastic shell, custom-fabricated
• L1833: Knee orthosis, adjustable knee joints, positional, rigid support, prefabricated, off-the-shelf

Phased rollout:

• L3761: Elbow orthosis, adjustable position locking joint(s), prefabricated, off-the-shelf
• L3916: Wrist hand orthosis, nontorsion joint(s), prefabricated, off-the-shelf
  

CMS is also adding the air fluidized bed (E0194) and the ultra-lightweight manual wheelchair (K0005) to the prior authorization list on the same date.

Don't miss the second requirement

All six of these codes were also added to CMS's Face-to-Face Encounter and Written Order Prior to Delivery (F2F/WOPD) List. For these items, you need a qualifying encounter, a compliant written order, and a provisional affirmation, all before delivery. 

Watch L3761 and L3916. Prior authorization is phased by state, but the F2F/WOPD requirement applies nationwide on October 28. A practice outside the first four states has no authorization requirement yet, but still needs the encounter and order before delivery.

• No authorization, no payment. For codes on the list, submit a prior authorization request (PAR) to your DME MAC before delivery. Claims billed without a decision and UTN are denied automatically.
• Standard reviews take 5 business days, not exceeding 7 calendar days. Expedited reviews take 2 business days and are for cases where waiting could seriously jeopardize the patient's health.
• Emergencies have a separate path. When even a 2-day expedited review would put the patient's health or life at risk, suppliers can append the ST modifier to bypass prior authorization. Talk with your compliance lead before using it.
• Medicare as secondary still requires it. Prior authorization is needed to bill Medicare even when another payer is primary.
• Affirmations for orthoses are good for 60 days. If you don't deliver within that window, you'll need a new request.
• The UTN goes on the claim. Each HCPCS code has its own UTN. On the CMS-1500, enter it in Item 23 (one UTN per claim form). Electronic claims carry one UTN per claim line.
• You can resubmit a non-affirmed request as many times as you need. Each resubmission should fix the specific issues the reviewer identified.
• Strong results can earn an exemption. Suppliers that reach a 90% provisional affirmation rate in a MAC jurisdiction may qualify for a one-year exemption, reviewed annually. Clean first submissions pay off.
  

1. Start at the referral, not the fitting
The most common prior authorization problem is timing. A practice evaluates the patient, gets ready to fit, and then learns the code needs authorization. Flag affected codes as soon as a referral comes in. If the item is on the list, start gathering documentation that day.

2. Build a complete packet before you submit
Reviewers decide based on what's in front of them, and getting it right the first time is faster than resubmitting. For orthoses, a strong packet usually includes: 

• A compliant written order with the patient's name or MBI, order date, item description, quantity, and the treating practitioner's name or NPI and signature 
• Face-to-face encounter notes from the treating practitioner showing medical need, with objective findings, not just a diagnosis 
• Your clinical evaluation, including measurements, functional limitations, and why this specific device (off-the-shelf, custom-fitted, or custom-fabricated) is appropriate 
• Documentation that addresses each coverage criterion in the applicable Local Coverage Determination (LCD) and policy article

For lower-limb prosthetics, reviewers also look closely at functional level (K-level) documentation and whether the prosthetist's notes are consistent with the physician's records.

3. Make sure your notes and the physician's notes agree

Reviewers expect the treating practitioner's medical record to support the need for the device on its own. Your notes can add detail, but they can't be the only source of medical necessity. If the physician's note says "back pain" and yours describes post-surgical instability, the request is at risk. When there's a gap, ask the referral source for an addendum before you submit.

4. Learn from every non-affirmation

A non-affirmation comes with detailed reasons. Track them. If the same issues keep showing up, such as missing signatures, out-of-date encounter notes, or LCD criteria that aren't addressed, fix the problem in your intake process, not just in the one case.

5. Watch the 60-day clock 

An affirmation that expires before delivery means starting over. Custom-fabricated devices, backordered components, and patients who need to reschedule can all push delivery past the window. Track affirmation dates next to fitting appointments so nothing lapses.



6. Know your state's rollout phase

Make sure your team knows which phase your state is in for L3761 and L3916, especially if you have locations in more than one state.

• Add the six new codes to your prior authorization flags and intake checklists.
• Confirm which phase each of your states is in for L3761 and L3916.
• Build a standard documentation packet template for TLSOs and off-the-shelf knee orthoses.
• Tell your top referral sources what documentation you'll need from them, and why turnaround matters.
• Set up tracking for submission dates, decisions, UTNs, and 60-day expirations.
• Brief front desk, fitting, and billing staff on the difference between the authorization requirement and the F2F/WOPD requirement.
  

Nymbl is built to keep requirements visible where the work happens, so the prior authorization step isn't discovered at the fitting. Practices can use Nymbl to:

• Flag codes that need authorization. Set alerts in the work-in-progress (WIP) view for specific HCPCS and payer combinations, so gaps surface while the order is in progress and again when it's time to bill.
• Keep orders current. If a practitioner updates codes after a standard written order has gone out, Nymbl flags the admin team that new documentation is needed.
• Build the packet from the chart. Pre-fill forms with the form builder, and generate editable SOAP notes from dictation to support your clinical evaluation.
• Start with clean intake. One-page intake with validation rules helps referrals get processed faster and more accurately.
• Check claims before they go out. A quick claim check runs from proof of delivery, and an optional real-time rules engine can warn your team about problems before submission.
• See where work stalls. Built-in dashboards show days to pay by payer and bottlenecks, so you can find the step that slows approvals and payment.
• Track prior authorization status and UTNs. Follow each request through prescription statusing and the Prior Authorization section of the WIP view, where your team can log status updates, notes, and UTNs.
• Get alerts before an affirmation expires. Enter the expiration date in the WIP view, and Nymbl notifies the assigned user (and anyone else you configure) two weeks out, one week out, and when it expires. The Prescription Summary also updates at seven days out and at expiration.
• Build authorization into your workflow. Add prior authorization confirmation to your customizable prescription status workflow so it has to be addressed before delivery.

For practices that need extra hands, Nymbl's revenue cycle management services include claim review before submission and denial management.

• Lower-limb prosthetics (6): L5856, L5857, L5858, L5973, L5980, L5987 
• Spinal orthoses (9): L0456 (new), L0457 (new), L0486 (new), L0631, L0637, L0639, L0648, L0650, L0651 
• Knee orthoses (8): L1832, L1833 (new), L1843, L1844, L1845, L1846, L1851, L1852 
• Ankle-foot orthoses (2): L1932, L1951 
• Upper-extremity orthoses (2): L3761 (new, phased), L3916 (new, phased)

The full list is on the CMS website. 

Prior authorization delays don't just affect your revenue cycle. They affect patients who are waiting to get back on their feet, return to work, or recover from surgery. A clean, complete first submission gets decisions back faster and lets your team give patients a realistic timeline from the start.

Prior authorization is now a routine part of O&P, the list keeps growing, and a missed authorization means a denied claim. The practices that do well will start at intake, submit complete packets, and track every request through to delivery.



Don't let October 28 slow your practice down. Be proactive, be prepared, and get paid correctly from day one. 

If you'd like to learn more about how we can help you with this and more, book a demo of Nymbl today.

About the author: Jessica Glenn is Director of Product Management at Nymbl, where she translates payer-provider complexity into intuitive tools that streamline claims, authorizations, and payment collection. She brings over a decade of experience building healthcare revenue cycle solutions.