I 
115TH CONGRESS 
1ST SESSION H. R. 2445 
To amend title XVIII of the Social Security Act to provide for a prior 
authorization process under the Medicare program for certain high cost 
durable medical equipment, prosthetics, orthotics, and supplies. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 16, 2017 
Mrs. BLACKBURN introduced the following bill; which was referred to the 
Committee on Energy and Commerce, and in addition to the Committee 
on Ways and Means, for a period to be subsequently determined by the 
Speaker, in each case for consideration of such provisions as fall within 
the jurisdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for a prior authorization process under the Medicare 
program for certain high cost durable medical equipment, 
prosthetics, orthotics, and supplies. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘DMEPOS Access and 
Transparency Act of 2017’’ or the ‘‘DATA Act of 2017’’. 
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SEC. 2. PRIOR AUTHORIZATION PROCESS FOR CERTAIN 
HIGH COST DURABLE MEDICAL EQUIPMENT, 
PROSTHETICS, ORTHOTICS, AND SUPPLIES 
UNDER THE MEDICARE PROGRAM. 
Section 1834(a)(15) of the Social Security Act (42 
U.S.C. 1395m(a)(15)) is amended— 
(1) in the paragraph heading, by striking 
‘‘ITEMS’’ and inserting ‘‘ITEMS; PRIOR AUTHORIZA-
TION PROCESS FOR CERTAIN HIGH COST DURABLE 
MEDICAL
EQUIPMENT, PROSTHETICS, ORTHOTICS, 
AND SUPPLIES’’; and 
(2) by adding at the end the following new sub-
paragraphs: 
‘‘(D) PRIOR AUTHORIZATION PROCESS FOR 
CERTAIN HIGH COST DURABLE MEDICAL EQUIP-
MENT, PROSTHETICS, ORTHOTICS, AND
SUP-
PLIES.— 
‘‘(i) IN GENERAL.—Not later than 1 
year after the date of the enactment of this 
subparagraph, the Secretary shall develop 
and implement a prior authorization proc-
ess for certain durable medical equipment, 
prosthetics, orthotics, and supplies. A 
claim for an item of durable medical equip-
ment, a prosthetic, an orthotic, or a supply 
that has received prior approval through 
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the prior authorization process shall be ex-
empt from subsequent pre- and post-pay-
ment audits and only subject to audits for 
systematic fraud and abuse. 
‘‘(ii) CONSIDERATION OF FACTORS.— 
The Secretary shall consider the following 
factors in developing and implementing the 
prior authorization process under this sub-
paragraph: 
‘‘(I) Beneficiary access to timely 
care. 
‘‘(II) Alignment with the best 
practices of commercial managed care 
plans and Medicare Advantage plans 
under part C that have expertise in 
prior authorization processes. 
‘‘(III) Implementation of stand-
ard medical necessity evaluation prior 
authorization requests for physician 
and hospital referral agents and non- 
physician practitioners. 
‘‘(IV) Accounting for same day 
delivery expectations by providing for 
expedited emergency review for cer-
tain items. 
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‘‘(iii) IMPLEMENTATION.—The Sec-
retary shall promulgate a regulation to 
carry out the prior authorization process 
under this subparagraph. The regulation 
shall— 
‘‘(I) ensure that stakeholders 
participate in the development of the 
process; and 
‘‘(II) place priority on prior au-
thorization of items that are subject 
to a high number of contractor audits. 
‘‘(E) PRIOR AUTHORIZATION PROCESS FOR 
HOME RESPIRATORY THERAPY.— 
‘‘(i) IN
GENERAL.—In the case of 
home respiratory therapy (as defined in 
clause (v)) furnished on or after January 
1, 2019, the Secretary shall establish and 
implement a process under which the Sec-
retary shall determine, in advance of fur-
nishing such therapy to an individual, 
whether payment for such therapy may not 
be made under this title because such ther-
apy is not covered under this title or be-
cause 
of 
the 
application 
of 
section 
1862(a)(1). 
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‘‘(ii) ELEMENTS OF PROCESS.—Under 
the process described in clause (i), with re-
spect to home respiratory therapy for an 
individual, the following shall apply: 
‘‘(I) In order to obtain a prior 
authorization under such process, the 
prescribing practitioner (as defined by 
the Secretary) prescribing such ther-
apy for such individual shall submit, 
for such therapy and individual— 
‘‘(aa) a prescription; 
‘‘(bb) in the case of home 
respiratory therapy that is oxy-
gen or oxygen equipment, a cer-
tificate of medical necessity; and 
‘‘(cc) a prior authorization 
form that includes the informa-
tion described in subclause (II). 
A prescription described in item (aa) 
with respect to such therapy is not re-
quired under this subclause if a cer-
tificate of medical necessity described 
in item (bb) with respect to such ther-
apy is provided and if such certificate 
contains a narrative description that 
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includes the elements for a prescrip-
tion, as set forth by the Secretary. 
‘‘(II) The Secretary shall provide 
a prior authorization form (initially on 
paper and, not later than 3 years 
after the date of the enactment of this 
subparagraph, in an electronic for-
mat) for prescribing practitioners (as 
so defined by the Secretary) to com-
plete when requesting a prior author-
ization under this subparagraph. The 
form shall constitute the complete re-
quest for information to determine 
medical necessity and require the pre-
scribing practitioner (as so defined by 
the Secretary) to provide each of the 
following: 
‘‘(aa) The date that the in-
dividual was seen by a pre-
scribing practitioner (as so de-
fined by the Secretary) within 
the appropriate timeframes for 
certification of the need for the 
therapy. 
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‘‘(bb) The result of the 
original blood gas, saturation test 
results, or sleep study results, as 
applicable. 
‘‘(cc) A statement that the 
individual needs or is using the 
therapy. 
‘‘(III) The Secretary shall re-
spond to the prescribing practitioner 
(as so defined by the Secretary) mak-
ing the prior authorization request 
within 72 hours (3 calendar days) of 
receiving the request. For hospital 
discharges, in the case of home res-
piratory therapy consisting of equip-
ment or supplies, the Secretary shall 
establish an expedited review process 
to allow for the equipment or supplies 
to be delivered on the same day it is 
ordered. 
‘‘(IV) The Secretary shall com-
municate the response to the pre-
scribing practitioner (as so defined by 
the Secretary) making the prior au-
thorization request and to the supplier 
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ment reviews as they relate to documenting 
medical necessity. 
‘‘(iv) IMPLEMENTATION.—The Sec-
retary may carry out this subparagraph 
through notice and comment rulemaking or 
by interim final rule with comment period. 
In establishing and implementing the proc-
ess under this subparagraph, the Secretary 
shall consult with stakeholders through 
formal and informal mechanisms. 
‘‘(v) HOME
RESPIRATORY
THERAPY 
DEFINED.—For purposes of this subpara-
graph, the term ‘home respiratory therapy’ 
means— 
‘‘(I) equipment, supplies, and 
services for home oxygen, home sleep, 
and mechanical ventilation; and 
‘‘(II) any other equipment, sup-
ply, or service specified by the Sec-
retary by regulation.’’. 
Æ 
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