Aetna considers medically necessary an external breast prosthesis following a medically necessary mastectomy. In addition, up to 4 post-mastectomy bras are considered medically necessary initially following a medically necessary mastectomy 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. 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.
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.
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.Background
This policy is supported by Durable Medical Equipment Medicare Administrative Contractor (DME MAC) policy.
BREAST PROSTHESIS, MASTECTOMY BRA, WITHOUT INTEGRATED BREAST PROSTHESIS FORM, ANY SIZE, ANY TYPE describes a bra with pockets that are intended to hold a mastectomy form or breast prosthesis held adjacent to the chest wall. These do not include an integrated breast prosthesis. They may be constructed of any material (e.g., cotton, polyester or other materials), with any type or location of closure, any size, with or without integrated structural support (e.g., underwire).
L8001 BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, UNILATERAL, ANY SIZE, ANY TYPE
L8002 BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, BILATERAL, ANY SIZE, ANY TYPE describe a bra with integrated breast prosthesis, either unilateral or bilateral, respectively. They may be constructed of any material (e.g., cotton, polyester or other materials), with any type or location of closure, any size, with or without integrated structural support (e.g., underwire).
EXTERNAL BREAST PROSTHESIS GARMENT, WITH MASTECTOMY FORM, POST MASTECTOMY describes a camisole type undergarment with polyester fill used post mastectomy.
A custom fabricated prosthesis is one which is individually made for a specific patient starting with basic materials. CUSTOM BREAST PROSTHESIS, POST MASTECTOMY, MOLDED TO PATIENT MODELdescribes a molded-to-patient-model custom breast prosthesis. It is a particular type of custom fabricated prosthesis in which an impression is made of the chest wall and this impression is then used to make a positive model of the chest wall. The prosthesis is then molded on this positive model.
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|Other CPT codes related to the CPB:|
|19300 - 19307||Mastectomy procedures|
|HCPCS codes covered if selection criteria are met:|
|A4280||Adhesive skin support attachment for use with external breast prosthesis, each|
|L8000||Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type|
|L8001||Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type|
|L8002||Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type|
|L8010||Breast prosthesis, mastectomy sleeve|
|L8015||External breast prosthesis garment, with mastectomy form, post mastectomy|
|L8020||Breast prosthesis, mastectomy form|
|L8030||Breast prosthesis, silicone or equal|
|L8032||Nipple prosthesis, reusable, any type,each|
|L8039||Breast prosthesis, not otherwise specified|
|HCPCS codes not covered for indications listed in the CPB:|
|L8031||Breast prosthesis, silicone or equal, with integral adhesive|
|L8035||Custom breast prosthesis, post mastectomy, molded to patient model|
|ICD-10 codes covered if selection criteria are met:|
|C50.011 - C50.919||Malignant neoplasm of breast|
|C79.81||Secondary malignant neoplasm of breast|
|D05.01 - D05.99||Carcinoma in situ of breast|
|N60.11 - N60.19||Diffuse cystic mastopathy [severe fibrocystic disease]|
|Z90.10 - Z90.13||Acquired absence of breast and nipple|