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CGS DME Prior Authorization Request Coversheet

DMEPOS suppliers in CGS's DME MAC Jurisdictions B and C place this coversheet on a Medicare prior authorization request for items on the Required Prior Authorization List: power mobility devices, pressure reducing support surfaces, lower limb prostheses, orthoses, pneumatic compression devices and manual wheelchairs. Clinicians meet it because it names the treating practitioner, whose face-to-face notes and order form the medical record behind the request.

Who completes it

The DMEPOS supplier completes the coversheet, including HCPCS codes, submission type, beneficiary and supplier details. The treating practitioner's name, NPI and contact details go in their own block, and the practitioner's records and order are attached.

Submitting and payment

How to submit it
The supplier sends it with the medical records through the myCGS portal, esMD, fax or mail. CMS sets a standard review time of no more than seven calendar days, and two business days for expedited requests.
Who pays
Claims for items requiring prior authorization must be associated with an affirmative prior authorization decision to be eligible for Medicare payment.

Good to know

  • A treating practitioner who wants a copy of the decision is marked under Decision Letter Request, and the CMS decision letter request form must be included with the submission.
  • Replacement of a power mobility device that was lost, stolen or irreparably damaged should be marked as an expedited review, with the rationale entered on the coversheet.
  • An affirmed power mobility device decision stays valid for six months; if the device is not delivered in that window, the supplier must send a new request.
  • The Required Prior Authorization List grew on October 28, 2026, adding the K0005 manual wheelchair base, the E0194 support surface and more orthoses. Jurisdiction B posts its own copy of the coversheet.

Get the official form

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

Prior Authorization Request for Durable Medical Equipment Coversheet

Official pagePDF

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

Who fills out the CGS DME prior authorization coversheet?

The DMEPOS supplier. It lists the supplier, beneficiary and HCPCS codes, plus a block for the treating practitioner's name, NPI, phone, fax and address. The practitioner's face-to-face notes and order travel with it as supporting medical records rather than as a section the practitioner fills in.

How does the treating practitioner get the prior authorization decision letter?

The coversheet has a Decision Letter Request area with boxes for the beneficiary and the treating practitioner. A practitioner copy requires the CMS Prior Authorization Decision Request Letter for Physicians, completed and signed by the practitioner, to be included with the supplier's request.

How long does CGS take to decide a power mobility device prior authorization?

CGS sends a detailed decision letter by the fifth business day after receipt, not exceeding seven calendar days. When an expedited request gives a valid reason, CGS makes reasonable efforts to send a decision within two business days.