Prior Authorization Reminders

Published in VGM Complex Rehab Community on October 21, 2026

Featuring Dan Fedor, National Director of Rehab, VGM

Evolving prior authorization requirements have a direct impact on approval rates, reimbursement, and day-to-day complex rehab operations.

In a recent HME News article, VGM expert Dan Fedor shares important reminders about:

Medicare’s prior authorization exemption program
Documentation and coding errors that can lead to denials
Upcoming requirements for K5 wheelchairs
The rise of claim-level denials under Medicare Advantage plans

The takeaway? Accurate documentation, compliant processes, and proactive reimbursement strategies are essential for improving approval rates, navigating policy changes, protecting revenue, and reducing administrative burden.

Need help understanding prior authorization tips or how reimbursement changes may affect your complex rehab operation? Connect with the VGM Complex Rehab Community for education, expert insight, and practical resources designed to help providers strengthen funding readiness and navigate reimbursement changes.

Read the original HME News article here or continue below:

Prior auth reminders

VGM’s Dan Fedor advises on exemptions, denials, & more

This article was written by Liz Beaulieu and originally appeared in HME News.

A new Medicare program that allows certain complex rehab technology (CRT) providers to bypass prior authorization requirements is highlighting a challenge for many: Their approval rates aren’t high enough to qualify.

Providers must maintain a prior authorization approval rate of at least 90% to earn an exemption from requirements for select items, but many have fallen short of that benchmark, according to Dan Fedor, [former] director of reimbursement and education for [The VGM Complex Rehab Community, previously known as] U.S. Rehab, a division of VGM.

“Many providers didn’t hit the 90%, which surprised them,” he said. “That’s definitely something they want to look at.”

Why Some Providers Aren’t Qualifying

Fedor says documentation and coding errors continue to drive many prior authorization denials.

Among the most common issues:

Wheelchair bases are miscoded as multiple-power chairs instead of single-power chairs due to seat elevation and/or power leg rests
The standard written order (SWO) is dated before completion of the face-to-face evaluation and the LMCP specialty evaluation. (Both must be 100% completed, signed, dated, cosigned, and dated before the SWO can be written.)
The assistive technology professional (ATP) assessment occurs before the face-to-face evaluation and the LMCP specialty wheelchair evaluation
All least costly alternatives are not ruled out with objective measurements by the treating practitioner or the LMCP in the wheelchair evaluation. (The ATP can’t document the medical necessity for any Medicare-covered item even if they disclose that they completed it.)

“These are the top [issues] that I see,” he said.

Addressing those issues could help providers improve approval rates and potentially qualify for Medicare’s exemption program, Fedor says.

K5 Wheelchairs Move to Prior Authorization

Another significant change is coming this fall. Beginning Oct. 28, [2026], Medicare will require prior authorization for K5 ultralightweight, highly customizable manual wheelchairs.

Fedor says this offers advantages compared to the advanced determination of Medicare coverage (ADMC) process currently used for K5 wheelchairs. Under prior authorization, providers can expect a decision within five to seven days, compared to as many as 30 days under the ADMC process.

Providers will also be able to submit an unlimited number of prior authorization requests, compared to the ADMC limit of two requests every six months.

“That’s huge,” Fedor said.

The tradeoff, however, is that Medicare’s prior authorization review will focus only on wheelchair bases. Under the ADMC process, providers can obtain review of both bases and accessories.

The Rise of Claim-Level Denials by Medicare Advantage Plans

Fedor says suppliers are increasingly encountering a different problem under Medicare Advantage plans: Prior authorizations are being approved, only for claims to be denied later.

Over the past year, he has seen plans become more likely to approve prior authorization requests while shifting scrutiny to the claims stage.

“It used to be they would deny prior authorizations for some frivolous reason, but now they’ve figured out if they do that, the patient is mad, the physician is mad, and the supplier is mad,” he said. “If they approve the prior authorization and deny at a claim level, the product is delivered, and everyone is happy, except for the supplier, who has to go through the appeals process.”

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