L8515 — Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of recommendation for device use by a laryngologist or a speech-language pathologist for voice rehabilitation following total laryngectomy.
- Documentation of total laryngectomy / clinical indication for voice restoration (diagnosis codes such as C32.x, D02.0, D14.1, Z85.21 where applicable).
- Clinical documentation that member has adequate pulmonary function to force air from the trachea through the prosthesis into the esophagus (assessment of pulmonary reserve).
- Clinical documentation that member has the manual dexterity to care for and clean the voice prosthesis daily.
Key Coverage Criteria
- Voice rehabilitation following total laryngectomy: indwelling tracheo-esophageal (TE) voice prosthesis is medically necessary when recommended by a laryngologist or a speech-language pathologist (see Appendix selection criteria).
- Replacement of indwelling TE voice prosthesis is medically necessary (replacement every 3 to 6 months is consistent with the documented life span of most prostheses).
- Hand-held artificial larynx devices (examples listed: Nu-Vois, OptiVox, Servox, SolaTone, TruTone, UltraVoice) are medically necessary for voice rehabilitation after total laryngectomy.
- Non-indwelling voice prostheses (e.g., Provox NiD) are medically necessary when recommended by a laryngologist or a speech-language pathologist for voice rehabilitation following total laryngectomy.
- Covered CPT code (if selection criteria met): 31611 - Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis.
- Other related CPT codes noted: 31360-31365 (total laryngectomy).
1 Active Policy
AETNA-CPB-0560 — Voice Prosthesis for Voice Rehabilitation Following Total Laryngectomy
Related Codes
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