Z90.10 — Acquired absence of unspecified breast and nipple
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The diagnosis code must be included on every claim for the prosthesis or related item.
- A treating practitioner's new order explaining the need for a different type of breast prosthesis must be created and retained in the supplier's files whenever the patient's medical condition changes; the order need not be submitted with the claim.
- Documentation created by an orthotist or prosthetist is considered part of the patient's medical record and may support the treating practitioner's documentation for prosthetics per Social Security Act §1834(h)(5).
- For items subject to Final Rule 1713, a prior face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required and the WOPD must be in the supplier's files before delivery; absence of these documents results in denial.
Key Coverage Criteria
- Custom fabricated breast prostheses, including molded-to-patient-model prostheses (HCPCS L8035), are covered when individually made for a specific patient and meet LCD reasonable and necessary criteria.
- External breast prostheses are covered under the Prosthetic Devices benefit when the prosthesis is reasonable and necessary and meets the requirements of the related Local Coverage Determination (LCD).
- Adhesive skin support (HCPCS A4280) is covered when used to attach an external breast prosthesis directly to the chest wall and when R&N requirements are met.
- Reconstructive breast surgery after a medically necessary mastectomy.
- Reconstructive breast surgery after a medically necessary lumpectomy that results in a significant deformity (i.e., mastectomy or lumpectomy for treatment of or prophylaxis for breast cancer and mastectomy or lumpectomy performed for chronic, severe fibrocystic breast disease, unresponsive to medical therapy).
- Harvesting (via lipectomy or liposuction) and grafting of autologous fat as a replacement for implants for breast reconstruction, or to fill defects after breast conservation surgery or other reconstructive techniques (medically necessary).
8 Active Policies
A52478 — External Breast Prostheses - Policy Article
J19
AETNA-CPB-0097 — External Breast Prosthesis
AETNA-CPB-0185 — Breast Reconstructive Surgery
AETNA-CPB-0244 — Skin and Soft Tissue Substitutes
AETNA-CPB-0031 — Cosmetic Surgery and Procedures
Related Codes
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