SUPERCEDED LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}

Noridian Administrative Services
Contractor Number ^{back to top}
19003
Contractor Type ^{back to top}
DME MAC

LCD Information

LCD ID Number ^{back to top}

L11569

LCD Title ^{back to top}
External Breast Prostheses

Contractor's Determination Number ^{back to top}
EBP

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 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.

CMS National Coverage Policy ^{back to top}
None

Primary Geographic Jurisdiction ^{back to top}
Alaska American Samoa Arizona California - Entire State Guam Hawaii Iowa Idaho Kansas Missouri - Entire State Montana North Dakota Nebraska Nevada Oregon South Dakota Utah Washington Wyoming Northern Mariana Islands

Oversight Region ^{back to top}
Region X

DME Region LCD Covers ^{back to top}
Jurisdiction D

Original Determination Effective Date ^{back to top}
For services performed on or after 10/01/1993

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 07/01/2007

Revision Ending Date ^{back to top}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
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.

Coding Information

Bill Type Codes: ^{back to top}

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes: ^{back to top}

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes ^{back to top}

The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service.
LT - Left side
RT - Right side

A4280	ADHESIVE SKIN SUPPORT ATTACHMENT FOR USE WITH EXTERNAL BREAST PROSTHESIS, EACH
L8000	BREAST PROSTHESIS, MASTECTOMY BRA
L8001	BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, UNILATERAL
L8002	BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, BILATERAL
L8010	BREAST PROSTHESIS, MASTECTOMY SLEEVE
L8015	EXTERNAL BREAST PROSTHESIS GARMENT, WITH MASTECTOMY FORM, POST MASTECTOMY
L8020	BREAST PROSTHESIS, MASTECTOMY FORM
L8030	BREAST PROSTHESIS, SILICONE OR EQUAL
L8035	CUSTOM BREAST PROSTHESIS, POST MASTECTOMY, MOLDED TO PATIENT MODEL
L8039	BREAST PROSTHESIS, NOT OTHERWISE SPECIFIED

ICD-9 Codes that Support Medical Necessity ^{back to top}

The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on “Indications and Limitations of Coverage and/or Medical Necessity” for other coverage criteria and payment information.

174.0	MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST
174.1	MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST
174.2	MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST
174.3	MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST
174.4	MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST
174.5	MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST
174.6	MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST
174.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST
174.9	MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE
233.0	CARCINOMA IN SITU OF BREAST
V45.71	ACQUIRED ABSENCE OF BREAST

Diagnoses that Support Medical Necessity ^{back to top}

Refer to the previous section.

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

All ICD-9 codes and diagnoses that are not specified in the preceding section.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

All diagnoses that are not specified in the preceding section.

General Information

Documentation Requirements ^{back to top}

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider". It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

The ICD-9 diagnosis code must be included on each claim for the prosthesis or related item.

If the patient's medical condition changes, this should be documented by the patient's physician submitting a new order which explains the need for a different type of breast prosthesis. The order must be kept in the supplier's files but need not be submitted with the claim.

Refer to the Supplier Manual for more information on documentation requirements.

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision ^{back to top}

Advisory Committee Meeting Notes ^{back to top}

Start Date of Comment Period ^{back to top}

04/15/1993

End Date of Comment Period ^{back to top}

05/31/1993

Start Date of Notice Period ^{back to top}

08/01/1993

Revision History Number ^{back to top}

EBP009

Revision History Explanation ^{back to top}

Revision Effective Date: 07/01/2007
INDICATIONS AND LIMITATIONS OF COVERAGE:
Removed: DMERC reference.
DOCUMENTATION REQUIREMENTS:
Removed: DMERC references.

Revision Effective Date: 03/01/2006
In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC Electronic Data Systems Corp. (77006) from DMERC CIGNA Government Services (05655).

Revision Effective Date: 07/01/2004
Converted LMRP to LCD and Policy Article.

Revision Effective Date: 04/01/2003
HCPCS CODES AND MODIFIERS:
Added: EY modifier.
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added standard language concerning coverage of items without an order.
CODING GUIDELINES:
Deleted: K0400 crosswalk to A4280 instructions from 2000.
COVERED ICD-9 CODES:
Added: 233.0
DOCUMENTATION REQUIREMENTS:
Added standard language concerning use of EY modifier for items without an order.

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

01/01/2002 – Revised Coverage and Payment Rules section including rules for useful lifetime expectancy for external breast prostheses and utilization guidelines. Added instructions for use of RT and LT modifiers in Coding Guidelines section.

01/01/2000 – Added HCPCS code A4280. Added Definitions section. Revised Coverage and Payment Rules, including specific ICD-9 codes for coverage, least costly language for L8035, and rules for L8015 for use in the postoperative period. Revised Coding Guidelines section to include code K0400 and A4280. Revised Documentation section including language regarding diagnosis.

03/01/1998 – Added HCPCS code L8039. Removed effective date for K0400 in Coding Guidelines.

10/01/1996 – Revised Coding Guidelines section including instructions for number of units for same code for both breasts. Added effective date for code K0400.

10/01/1995 – Added HCPCS code K0400.

12/01/1993 – Added HCPCS code L8000.

3/1/2008- In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC Noridian Administrative Services (19003) LCD L11569 from DME PSC Electronic Data Systems Corp. (77006) LCD L11569.

Reason for Change ^{back to top}

Last Reviewed On Date ^{back to top}

Medicare Coverage Database

LCD for External Breast Prostheses (L11569)