CMS adds 22 wheelchair, brace and ventilator codes to Medicare's face-to-face list, and 8 to prior authorization, from Oct. 28

One hundred and five. That is how many Medicare equipment codes will require a recent visit with the ordering practitioner and a written order in the supplier’s hands before delivery, starting October 28, 2026 [1]. The count is 83 today [1].

CMS published the expansion in the Federal Register on July 30 as notice CMS-6109-N [1]. It adds 22 codes to the Required Face-to-Face Encounter and Written Order Prior to Delivery List, eight codes to the Required Prior Authorization List and 20 codes to the Master List of items that could be moved onto either list later [1].

What changed

The new face-to-face codes fall into seven groups: three lumbar-sacral orthoses, four lower limb orthoses, two upper limb orthoses, eight wheelchairs, three home ventilators, one oxygen system and one air fluidized bed [1]. The wheelchair codes are manual and standard models that many practices order routinely: K0002 through K0007, the E1161 tilt-in-space chair and K0831, a group 2 power chair with a seat elevator [1]. The ventilators are E0466, E0467 and E0468, and the oxygen code is K0738, a home compressor that fills portable cylinders [1].

The eight prior authorization codes are E0194, the air fluidized bed; K0005, the ultralightweight wheelchair; L1833, an off-the-shelf knee orthosis; three thoracic-lumbar-sacral orthoses, L0456, L0457 and L0486; and two upper limb orthoses, L3761 and L3916 [1]. Every one of the eight is also on the new face-to-face list [1].

Most of the changes take effect October 28 [1]. Prior authorization for the two upper limb orthoses comes in three phases: New York, Michigan, Florida and California on October 28; Pennsylvania, Massachusetts, Ohio, Illinois, Texas, Georgia, Arizona and Oregon added on January 26, 2027; and every other state and territory on April 26, 2027 [1]. The 74 codes already under prior authorization stay there [1].

This is the second list update this year. A January 13 notice, effective April 13, put eight oxygen codes on the face-to-face list and sent five orthoses and two pneumatic compression devices to nationwide prior authorization [2, 6].

Who it affects

Ordering practitioners. The condition of payment falls on the claim the supplier submits, but the work falls on whoever writes the order. Under section 1834(a)(11)(B)(ii) of the Social Security Act, a physician, physician assistant, nurse practitioner or clinical nurse specialist must write the order and document a face-to-face encounter in the six months before it [3].

Patients who need the equipment quickly. A brace or wheelchair can no longer be delivered first and papered afterward for these codes; the written order has to reach the supplier before delivery [1].

DMEPOS suppliers, who submit prior authorization requests and will lean on practices for chart notes to support them [1].

What it means for your practice

Take a patient you last saw nine months ago whose family now calls for a lightweight wheelchair, K0003. K0003 is not on the face-to-face list today [1]. After October 28, the claim needs an encounter with you, or another listed practitioner, within the six months before the order date [1]. That means a visit, though CMS notes that telehealth can meet the requirement when appropriate [1].

The note itself has to carry weight. CMS says the encounter must be documented in the medical record, and that the documentation must include “subjective and objective beneficiary-specific information” used to diagnose, treat or manage the condition the item is ordered for [1]. A line reading “needs wheelchair” will not hold up on review.

For the eight prior authorization codes there is a second step. Before delivery and before the claim, the requester must send CMS or its contractor the written order, relevant information from the patient’s medical record and the supplier’s own documentation, and a medical reviewer issues a provisional affirmation or non-affirmation [1]. Expect suppliers to ask for visit notes, imaging or therapy records sooner and more often for back and knee braces, the K0005 chair and air fluidized beds.

Why is CMS adding braces and wheelchairs now?

CMS points to its improper payment data. In its Comprehensive Error Rate Testing (CERT) program, the sample-based audit CMS uses to estimate payment errors, upper limb orthoses ran at improper payment rates of about 40% to 48% from 2023 through 2025, lower limb orthoses at 35% to 47%, and manual wheelchairs at 22.1% to 42% [1]. The 2025 CERT data put DMEPOS as a whole at a 24.1% improper payment rate, with $2.3 billion in projected improper payments [4].

The errors are mostly about paperwork. For lower limb orthoses in 2025, CERT attributed 46.4% of improper payments to insufficient documentation and 26.5% to no documentation; for upper limb orthoses the shares were 42.5% and 32.9% [4]. Only 8.7% and 2.2%, respectively, were medical necessity findings [4].

The notice also cites fraud. CMS refers to Justice Department cases involving “medically unnecessary equipment” and telemarketing aimed at Medicare beneficiaries, and says its Fraud Defense Operations Center has suspended more than $1.5 billion in DMEPOS payments tied to suspected fraud [1]. The DOJ case it footnotes involved a Florida man who ran five DME suppliers through nominee owners; the companies billed about $61.5 million in false claims and were paid about $26.7 million, and he was sentenced in July 2025 to 12 years [5].

Eight of the 20 new Master List codes, including the A4239 continuous glucose monitor supply allowance and two wound dressings, were added for aberrant billing: at least 1,000 claims, $1 million in payments and a payment jump of more than 30% from July 2024 to June 2025 with no explanation CMS could find [1]. Master List placement alone changes nothing for ordering practices; items carry conditions of payment only after a separate notice moves them onto a required list [1, 6].

What to do now

1. Update order sets before October 28. Add a prompt in your EHR for the 22 new codes so the six-month encounter check happens at the point of ordering [1].
2. Book visits, or telehealth visits, for patients likely to need these items. Patients with progressive neurological or orthopedic conditions who have not been seen recently are the ones to catch [1].
3. Write encounter notes that name the condition and the functional need. CMS’s standard is subjective and objective, patient-specific findings tied to the item [1].
4. Agree on a records process with your main suppliers. Prior authorization requests require the written order and relevant medical record information [1].
5. Watch for CMS’s operating guidance. CMS says it will issue sub-regulatory instructions and final review timelines for the new prior authorization items [1].
6. Comment on the replacement proposal by August 31. CMS-1844-P would let a same-code replacement go forward with a new order but no new encounter; this site covered that proposal in its report on the home health rule [3].

The policy fight

The notice does not open a comment period. CMS’s 2019 rule set up the process: it publishes list updates in the Federal Register at least 60 days before they take effect, and this time it gave at least 90 days for the prior authorization additions [1]. CMS estimates net savings of $15.8 million from the eight new prior authorization codes, after implementation costs, and says the change is not economically significant [1].

CMS’s case for adding the face-to-face codes is that “additional practitioner oversight” helps make sure patients get items matched to their medical needs [1]. On access, the agency says it has “not been notified of any issues related to beneficiary access” from the 83 items already on the face-to-face list, and that it can suspend prior authorization if it finds the process is creating barriers to care [1].

The phased rollout for upper limb orthoses is CMS’s own hedge: it says smaller claim volumes in the first two phases will let it “identify and resolve any unforeseen issues” before the requirement goes national [1].

How long a provisional affirmation will take for a back brace or a K0005 chair, and whether suppliers delay deliveries while they wait, depends on guidance CMS has not yet published [1].