L8035 — Custom breast prosthesis, post mastectomy, molded to patient model
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted for items addressed by this policy.
- For DMEPOS base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO/WOPD before delivering the item to the beneficiary.
- For base items requiring a WOPD and separately billed associated items, the WOPD must list the base item (and may list associated items) prior to delivery of any separately billed associated items.
- Suppliers are required to maintain proof of delivery (POD) documentation in their files and provide POD to the Medicare contractor upon request.
Key Coverage Criteria
- An external breast prosthesis is covered for a patient who has had a mastectomy.
- An external breast prosthesis garment with mastectomy form (HCPCS L8015) is covered for use in the postoperative period prior to a permanent prosthesis or as an alternative to a mastectomy bra and breast prosthesis.
- A mastectomy bra (HCPCS L8000) is covered when used with a covered mastectomy form (HCPCS L8020) or silicone (or equal) breast prosthesis (HCPCS L8030) and the bra pocket is used to hold the form/prosthesis.
- An external breast prosthesis of the same type may be replaced at any time if it is lost or irreparably damaged (excluding ordinary wear and tear).
- An external breast prosthesis of a different type may be covered at any time if a change in the patient's medical condition necessitates a different type of item.
- Covered ICD-10 diagnoses (listed as covered if selection criteria are met): D05.01 - D05.99 (Carcinoma in situ of breast)
4 Active Policies
L33317 — External Breast Prostheses
J19
AMBETTER-CP.MP.107 — Durable Medical Equipment and Orthotics and Prosthetics Guidelines
CIGNA-0178 — Breast Reconstruction Following Mastectomy or Lumpectomy - (0178)
AETNA-CPB-0097 — External Breast Prosthesis
Related Codes
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