I97.2 — Postmastectomy lymphedema syndrome
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- The diagnosis code must be included on every claim for the prosthesis or related item.
- A treating practitioner's new order explaining the need for a different type of breast prosthesis must be created and retained in the supplier's files whenever the patient's medical condition changes; the order need not be submitted with the claim.
- Documentation created by an orthotist or prosthetist is considered part of the patient's medical record and may support the treating practitioner's documentation for prosthetics per Social Security Act §1834(h)(5).
- For items subject to Final Rule 1713, a prior face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required and the WOPD must be in the supplier's files before delivery; absence of these documents results in denial.
Key Coverage Criteria
- Custom fabricated breast prostheses, including molded-to-patient-model prostheses (HCPCS L8035), are covered when individually made for a specific patient and meet LCD reasonable and necessary criteria.
- External breast prostheses are covered under the Prosthetic Devices benefit when the prosthesis is reasonable and necessary and meets the requirements of the related Local Coverage Determination (LCD).
- Adhesive skin support (HCPCS A4280) is covered when used to attach an external breast prosthesis directly to the chest wall and when R&N requirements are met.
- Occupational therapy is covered for patients with migraine (G43.xx) who require training to reduce pain during basic and instrumental activities of daily living, typically completed in 3–4 sessions.
- Electrical stimulation (attended CPT 97032 or unattended HCPCS G0283) may be covered as part of a therapy plan of care to improve function when the nerve supply to the muscle is intact and atrophy is due to non-neurological disuse (e.g., post-casting, splinting, soft-tissue scarring).
- Wheelchair management training (CPT 97542) is covered for patient and/or caregiver training in transfers and propulsion when documentation ties the training to attainable functional goals.
17 Active Policies
A52478 — External Breast Prostheses - Policy Article
J19
CIGNA-0354 — Compression Devices - (0354)
ANTHEM-MP-A050277 — ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
ANTHEM-CG-DME-06 — CG-DME-06 Compression Devices for Lymphedema
A53057 — Billing and Coding: Home Health Occupational Therapy
Related Codes
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