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DMEPOS Prior Authorization Decision Letter Request

This one-page CMS sample letter lets the treating physician or practitioner ask a DME Medicare Administrative Contractor for a copy of the prior authorization decision letter once review is complete. It applies when a DMEPOS supplier requests prior authorization for an item on Medicare's Required Prior Authorization List, such as a power mobility device, and it travels with the supplier's request.

Who completes it

The treating physician or practitioner completes and signs it, filling in the DME MAC jurisdiction, their name, the date, the patient's name and Medicare number, the HCPCS code and the address where the decision letter should go.

Submitting and payment

How to submit it
Give the signed letter to the supplier to include with its prior authorization request to the DME MAC; CGS's coversheet requires it with the submission when a practitioner copy is wanted.
Who pays
Medicare pays the supplier only when its claim is associated with an affirmative prior authorization decision for the item.

Good to know

  • The 'To' line reads DME MAC J followed by a blank for the jurisdiction letter; use the jurisdiction the supplier is sending the request to.
  • Identify the patient by name and HIC or Medicare Beneficiary Identifier, and list the HCPCS code so the contractor can match the letter to the supplier's request.
  • CMS sets a standard review time of no more than seven calendar days for DMEPOS prior authorization, and two business days for expedited requests.
  • The sample was created in October 2018 and is listed in the downloads on CMS's DMEPOS prior authorization program page.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization Decision Request Letter for Physicians

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

How does a physician get a copy of a DMEPOS prior authorization decision?

By completing and signing CMS's Prior Authorization Decision Request Letter for Physicians and having the supplier include it with the prior authorization request. CGS's coversheet has a Decision Letter Request box for the treating practitioner and says the letter must be included with the submission.

Which items does the decision letter request apply to?

Any DMEPOS item on Medicare's Required Prior Authorization List, which includes power mobility devices, pressure reducing support surfaces, lower limb prostheses, certain orthoses, pneumatic compression devices and, from October 28, 2026, the K0005 manual wheelchair base.

Does the decision letter request need a signature?

Yes. The one-page letter ends with a signature line for the treating physician or practitioner, under a request asking the DME MAC to send a copy of the decision letter to the address given once the review is complete.