L8045 — Auricular 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.
- the procedure is reasonably expected to improve the functional impairment;and
- an audiogram documents a loss of at least 15 decibels in the affected ear(s).
- Facial plastic surgery is consideredmedically necessarywhen required tocorrect a significant functional impairmentandthe procedure can be reasonably expected to improve the functional impairment. Examples include, but are not limited to, reconstructive procedures which correct or improve a significant functional impairment of speech, nutrition, control of secretions, protection of the airway, or corneal protection.
- Facial plastic surgery is consideredreconstructivewhen intended to address a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.Note:The initial restoration may be completed in stages.
4 Active Policies
L33738 — Facial Prostheses
J19
AMBETTER-CP.MP.107 — Durable Medical Equipment and Orthotics and Prosthetics Guidelines
ANTHEM-MP-A050276 — ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
ANTHEM-CG-MED-96 — CG-MED-96 Prefabricated External Infant Ear Molding Systems
Related Codes
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