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CPT codes, descriptions and other data only are copyright 2006
American Medical Association (or such other date of publication of CPT).
All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental
Terminology, (CDT) (including procedure codes, nomenclature, descriptors
and other data contained therein) is copyright by the American Dental
Association. © 2002, 2004 American Dental Association. All rights reserved.
Applicable FARS/DFARS apply.
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For any item to be covered by Medicare, it must 1) be eligible
for a defined Medicare benefit category, 2) be reasonable and necessary for
the diagnosis or treatment of illness or injury or to improve the functioning
of a malformed body member, and 3) meet all other applicable Medicare
statutory and regulatory requirements. For the items addressed in this
medical policy, the criteria for "reasonable and necessary" are
defined by the following indications and limitations of coverage and/or
medical necessity.
For an item to be covered by Medicare, a written signed and dated order
must be received by the supplier before a claim is submitted. If the
supplier bills for an item addressed in this policy without first receiving
the completed order, the item will be denied as not medically necessary.
A breast prosthesis is covered for a patient who has had a mastectomy,
ICD-9-CM diagnosis codes V45.71, 174.0-174.9, or 233.0.
An external breast prosthesis garment, with mastectomy form (L8015) is
covered for use in the postoperative period prior to a permanent breast
prosthesis or as an alternative to a mastectomy bra and breast prosthesis.
The additional features of a custom fabricated prosthesis (L8035), compared
to a prefabricated silicone breast prosthesis, are not medically necessary.
Therefore, if an L8035 breast prosthesis is provided to a patient who has
had a mastectomy, payment will be based on the allowance for the least
costly medically appropriate alternative, L8030.
An external breast prosthesis of the same type can be replaced at any time
if it is lost or is irreparably damaged (this does not include ordinary
wear and tear). An external breast prosthesis of a different type can be
covered at any time if there is a change in the patient's medical condition
necessitating a different type of item. The Medicare program will pay for
only one breast prosthesis per side for the useful lifetime of the
prosthesis. Two prostheses, one per side, are allowed for those persons who
have had bilateral mastectomies. More than one external breast prosthesis
per side will be denied as not medically necessary.
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