L8049 — Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments, 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.
- No explicit covered indications/diagnoses/clinical scenarios are provided in the supplied document excerpt.
- Replacement of a missing body part (prosthesis), including arms, breasts, ears, feet, hands, legs and maxillofacial (jaw and face).
- Lower limb prostheses designed to replace portions of the lower extremity to improve function.
- Use of a prosthetic knee to provide support during the stance phase of ambulation.
2 Active Policies
L33738 — Facial Prostheses
J19
HUMANA-PROSTHETICS-KY-MEDICAID — Prosthetics - MEDICAID - KENTUCKY
Related Codes
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