External Breast Prostheses - DME.MU.204.A

External breast prostheses (L8020-L8039), mastectomy bras/garments (L8000-L8002, L8015), nipple prostheses (L8032-L8033) and related attachments (A4280, A6549) are covered as medically necessary after mastectomy with specified per‑code quantity/frequency limits, while L8031 and L8035 are excluded. Coverage requires documentation of the mastectomy, use of RT/LT modifiers when applicable, mastectomy bras must have a pocket and be used with a covered form/prosthesis, adherence to the listed code‑specific limits (e.g., silicone prostheses typically one per side every 24 months, fabric/foam up to two per side per 12 months), and any additional supplies need documented medical necessity.

"An external breast prosthesis (HCPCS L8020-L8039) is medically necessary following a mastectomy for any of the following: As a permanent external breast prosthesis."

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