External Breast Prostheses - Policy Article

External breast prostheses (including custom molded devices and adhesive skin supports) are covered under the Prosthetic Devices benefit when reasonable and necessary per the related LCD and when statutory/payment requirements are met. Useful lifetime limits apply (silicone 2 years; fabric/foam/fiber 6 months; nipple 3 months) and specified items under Final Rule 1713 require a prior face-to-face encounter and Written Order Prior to Delivery; failure to meet documentation, modifier, or WOPD requirements will result in claim denial.

"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 (L..."

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