Z90.13 — Acquired absence of bilateral breasts and nipples
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 surgery is covered for abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease when performed to improve function or approximate normal appearance.
- Removal of breast implant(s) is covered when the medical record documents a condition that makes removal medically reasonable and necessary.
- Breast reduction (reduction mammoplasty) is covered when clinical evaluation documents macromastia with signs/symptoms, height/weight and BSA are recorded, and back/neck/shoulder pain is unrelieved by at least 6 months of conservative treatment, with operative and pathology reports documenting the weight of tissue removed from each breast.
14 Active Policies
L39051 — Cosmetic and Reconstructive Surgery
J05
A58774 — Billing and Coding: Cosmetic and Reconstructive Surgery
J05
A52478 — External Breast Prostheses - Policy Article
J19
AETNA-CPB-0244 — Skin and Soft Tissue Substitutes
AETNA-CPB-0297 — Cryoanalgesia and Therapeutic Cold
Related Codes
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