L8042, Orbital prosthesis, provided by a non-physician
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A completed Standard Written Order (SWO) must be communicated to the supplier before claim submission; for items requiring WOPD the SWO must be signed prior to delivery.
- Suppliers must maintain Proof of Delivery (POD) documentation and make POD available to the Medicare contractor upon request.
- Claims must comply with CMS HCPCS coding guidelines, LCDs, LCD-related Policy Articles, and DME MAC articles; suppliers should follow the LCD-related Standard Documentation Requirements Article and the LCD-related Policy Article and the Supplier Manual for additional documentation requirements.
- Suppliers should refer to DME MAC websites and bulletin articles for additional documentation and payment rule guidance relevant to this LCD.
Key Coverage Criteria
- Facial prosthesis is covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect.
- Any item is covered only if it is in a defined Medicare benefit category and is reasonable and necessary for diagnosis or treatment of illness or injury or to improve functioning of a malformed body member.
- Durable medical equipment, orthotics, and prosthetics that are necessary and reasonable for the treatment of an illness or injury or to improve the functioning of a physical deficit.
- Equipment expected to make a meaningful contribution to treatment of the patient’s illness or injury or to improvement of a malformed body member.
- Coverage only when education regarding use of the device has been provided with demonstrated understanding and a trial of the requested device has been completed with demonstrated ability to use it safely and effectively.
- DME is covered when it is medically necessary and reasonable to treat the member’s condition.
2 Active Policies
L33738, Facial Prostheses
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
Related Codes
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