Clinical Policy Bulletin: External Breast Prosthesis
Aetna considers medically necessary an external breast prosthesis and up to 4 post-mastectomy bras following a medically necessary mastectomy. Note: Some Aetna plans limit prosthetic coverage to an initial medically necessary prosthesis and do not cover replacement prostheses. Please check benefit plan descriptions for details. Under these plans, an initial external breast prosthesis and up to 4 initial post-mastectomy bras are covered following a medically necessary mastectomy. "Initial" applies to a breast prosthesis and bras purchased within 1 year after the mastectomy is performed, not the first breast prosthesis prescribed after the member's Aetna coverage becomes effective.
Aetna considers an external breast prosthesis garment with mastectomy form medically necessary for use in the post-operative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis.
Aetna considers 2 to 4 post-mastectomy replacement bras medically necessary every 12 months. One replacement silicone breast prostheses is considered medically necessary every 24 months. For fabric, foam, or fiber-filled breast prostheses, replacements are considered medically necessary every 6 months. Replacements of nipple prostheses are considered medically necessary every 3 months. The medical necessity of more frequent replacements must be documented. Note: Some Aetna plans limit coverage to an initial prosthesis and do not cover replacement prostheses. Please check benefit plan descriptions for details.
Aetna considers three mastectomy sleeves medically necessary initially, then two replacements every six months.
A breast prosthesis, silicone or equal, with integrated adhesive is considered not medically necessary because it has not been demonstrated to have a clinical advantage over those without the integrated adhesive.
Note: The additional features of a custom-fabricated breast prosthesis, compared to a pre-fabricated silicone breast prosthesis, are not considered medically necessary.
This policy is supported by Durable Medical Equipment Medicare Administrative Contractor (DME MAC) policy.
According to DME MAC policy, breast prostheses, silicone or equal, with integral adhesive are not considered medically necessary because they have not been demonstrated to have a clinical advantage over those without the integral adhesive.
Only 1 breast prosthesis per side are considered medically necessary for the useful lifetime of the prosthesis. Two prostheses, 1 per side, are considered medically necessary for those persons who have had bilateral mastectomies. More than 1 external breast prosthesis per side is considered not medically necessary.
A mastectomy bra is considered medically necessary for a member who has a medically necessary mastectomy form or silicone (or equal) breast prosthesis when the pocket of the bra is used to hold the form/prosthesis.
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
19300 - 19307
HCPCS codes covered if selection criteria are met:
Adhesive skin support attachment for use with external breast prosthesis, each
Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type
Breast prosthesis, mastectomy sleeve
External breast prosthesis garment, with mastectomy form, post mastectomy
Breast prosthesis, mastectomy form
Breast prosthesis, silicone or equal
Nipple prosthesis, reusable, any type,each
Breast prosthesis, not otherwise specified
HCPCS codes not covered for indications listed in the CPB:
Breast prosthesis, silicone or equal, with integral adhesive
Custom breast prosthesis, post mastectomy, molded to patient model
ICD-9 codes covered if selection criteria are met:
The above policy is based on the following references:
Reaby LL. Reasons why women who have mastectomy decide to have or not to have breast reconstruction. Plast Reconstr Surg. 1998;101(7):1810-1818.
Reaby LL. Breast restoration decision making: Enhancing the process. Cancer Nurs. 1998;21(3):196-204.
Korvenoja ML, Smitten K, Asko-Seljavaara S. Problems in wearing external prosthesis after mastectomy and patient's desire for breast reconstruction. Ann Chir Gynaecol. 1998;87(1):30-34.
Reaby LL, Hort LK. Postmastectomy attitudes in women who wear external breast prostheses compared to those who have undergone breast reconstructions. J Behav Med. 1995;18(1):55-67.
Reaby LL, Hort LK, Vandervord J. Body image, self-concept, and self-esteem in women who had a mastectomy and either wore an external breast prosthesis or had breast reconstruction and women who had not experienced mastectomy. Health Care Women Int. 1994;15(5):361-375.
Handel N. Current status of breast reconstruction after mastectomy. Oncology (Huntingt). 1991;5(11):73-84, 89, 90, 92.
van Dam FS, Bergman RB. Psychosocial and surgical aspects of breast reconstruction. Eur J Surg Oncol. 1988;14(2):141-149.
Tanner R, Abraham SF, Llewellyn-Jones D. External breast prostheses. A survey of their use by women after mastectomy. Med J Aust. 1983;1(6):270-272.
Snyderman RK. Alternatives in reconstructive surgery after mastectomy. Cancer. 1980;46(4 Suppl):1053-1058.
Smoot EC 3d, Silverman JJ, Cohen IK. The brassiere shop: A front line of assistance to the mastectomy patient. Ann Plast Surg. 1979;3(5):430-432.
Glaus SW, Carlson GW. Long-term role of external breast prostheses after total mastectomy. Breast J. 2009;15(4):385-393.
Gallagher P, Buckmaster A, O'Carroll S, et al. External breast prostheses in post-mastectomy care: Women's qualitative accounts. Eur J Cancer Care (Engl). 2010;19(1):61-71.
NHIC, Corp. Local Coverage Determination (LCD) for External Breast Prostheses (L5043). Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; effective June 1, 2012.
NHIC, Corp. Local Coverage Article for External Breast Prosthesis - Policy Article - Effective June 2012 (A19801). Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; effective June 1, 2012.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.