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External Breast Prosthesis

Number: 0097



Policy

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.

Background

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 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-9 codes covered if selection criteria are met:
174.0 - 175.9 Malignant neoplasm of breast
198.81 Secondary malignant neoplasm of breast
233.0 Carcinoma in situ of breast
610.1 Diffuse cystic mastopathy [severe fibrocystic disease]
V45.71 Acquired absence of breast and nipple
Other ICD-9 codes related to the CPB:
V43.82 Organ or tissue replaced by other means, breast
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 "+":
ICD-10 codes will become effective as of October 1, 2015 :
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


The above policy is based on the following references:
    1. 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.
    2. Reaby LL. Breast restoration decision making: Enhancing the process. Cancer Nurs. 1998;21(3):196-204.
    3. 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.
    4. 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.
    5. 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.
    6. Handel N. Current status of breast reconstruction after mastectomy. Oncology (Huntingt). 1991;5(11):73-84, 89, 90, 92.
    7. van Dam FS, Bergman RB. Psychosocial and surgical aspects of breast reconstruction. Eur J Surg Oncol. 1988;14(2):141-149.
    8. 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.
    9. Snyderman RK. Alternatives in reconstructive surgery after mastectomy. Cancer. 1980;46(4 Suppl):1053-1058.
    10. 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.
    11. Glaus SW, Carlson GW. Long-term role of external breast prostheses after total mastectomy. Breast J. 2009;15(4):385-393.
    12. 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.
    13. 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.  
    14. 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.


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