Aetna considers a superficial facial prosthesis medically necessary when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect, regardless of whether the facial prosthesis restores function. See CPB 0031 - Cosmetic Surgery.
Aetna considers adhesives, adhesive remover, and tape used in conjunction with a facial prosthesis medically necessary. Note: Other skin care products related to the prosthesis, including but not limited to cosmetics, skin cream, cleansers, etc., are not covered as they are not considered medical items.
Note: For information on ocular prostheses that are not part of orbital prostheses, see CPB 0619 - Eye Prosthesis.
Background
This policy is based upon Medicare DMERC policy.
An external nasal prosthesis is a removable superficial prosthesis that restores all or part of the nose. It may include the nasal septum.
An external mid-facial prosthesis is a removable superficial prosthesis that restores part or all of the nose plus significant adjacent facial tissue/structures, but does not include the orbit or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek, upper lip, or forehead.
An external orbital prosthesis is a removable superficial prosthesis that restores the eyelids and the hard and soft tissue of the orbit. It may also include the eyebrow. An orbital prosthesis may or may not include the ocular prosthesis component.
An external upper facial prosthesis is a removable superficial prosthesis that restores the orbit plus significant adjacent facial tissue/structures, but does not include the nose or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek or forehead.
An external hemi-facial prosthesis is a removable superficial prosthesis that restores part or all of the nose plus the orbit plus significant adjacent facial tissue/structures, but does not include any intraoral maxillary component.
An external auricular prosthesis is a removable superficial prosthesis that restores all or part of the ear.
A superficial partial facial prosthesis is a removable superficial prosthesis that restores a portion of the face but which does not specifically involve the nose, orbit or ear.
An external nasal septal prosthesis is a removable prosthesis that occludes a hole in the nasal septum but does not include superficial nasal tissue.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
21076
21077
21079
21080
21081
21082
21083
21085
21086
21087
21088
HCPCS codes covered if selection criteria are met:
A4364
Adhesive, liquid, or equal, any type, per oz.
A4365
Adhesive remover wipes, any type, per 50
A4450
Tape, non-waterproof, per 18 sq. in.
A4452
Tape, waterproof, per 18 sq. in.
A4455
Adhesive remover or solvent (for tape, cement or other adhesive), per oz.
A4456
Adhesive remover, wipes, any type, each
L8040
Nasal prosthesis, provided by a nonphysician
L8041
Midfacial prosthesis, provided by a nonphysician
L8042
Orbital prosthesis, provided by a nonphysician
L8043
Upper facial prosthesis, provided by a nonphysician
L8044
Hemi-facial prosthesis, provided by a nonphysician
L8045
Auricular prosthesis, provided by a nonphysician
L8046
Partial facial prosthesis, provided by a nonphysician
L8047
Nasal septal prosthesis, provided by a nonphysician
L8048
Unspecified maxillofacial prosthesis, by report, provided by a nonphysician
L8049
Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments, provided by a nonphysician
V2623
Prosthetic eye, plastic, custom
V2624
Polishing/resurfacing of ocular prosthesis
V2625
Enlargement of ocular prosthesis
V2626
Reduction of ocular prosthesis
V2627
Scleral cover shell
V2628
Fabrication and fitting of ocular conformer
V2629
Prosthetic eye, other type
Modifier KM
Replacement of facial prosthesis including new impression/moulage
Modifier KN
Replacement of facial prosthesis using previous master model
HCPCS codes not covered for indications listed in the CPB:
A6250
Skin sealants, protectants, moisturizers, ointments, any type, any size
A6260
Wound cleansers, any type, any size
ICD-9 codes covered is selection criteria are met (not all-inclusive):
743.00
Anophthalmos, congenital absence of eye
744.01
Absence of external ear
744.09
Other anomaly of ear causing impairment of hearing [absence of ear, congenital]
744.21
Absence of ear lobe, congenital
744.89
Other specified anomalies of face and neck [loss of facial tissue]
748.1
Other anomalies of nose [absent nose]
754.0
Congenital anomalies of skull, face, and jaw [absence of facial tissue]
V45.78
Acquired absence of organ, eye
Other ICD-9 codes related to the CPB:
738.0
Acquired deformity of nose
743.62
Congenital deformities of eyelids
743.66
Specified congenital anomalies of orbit
743.69
Other congenital anomalies of eyelids, lacrimal system, and orbit
744.29
Other specified anomalies of ear
The above policy is based on the following references:
NHIC, Corp. Facial prosthesis. Local Coverage Determination No. L5046. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised January 1, 2010.
NHIC, Corp. Facial prosthesis. Local Policy Article No. A25186. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised April 1, 2013.
Roumanas ED, Freymiller EG, Chang TL, et al. Implant-retained prostheses for facial defects: An up to 14-year follow-up report on the survival rates of implants at UCLA. Int J Prosthodont. 2002;15(4):325-332.
Chang TL, Garrett N, Roumanas E, Beumer J 3rd. Treatment satisfaction with facial prostheses. J Prosthet Dent. 2005;94(3):275-280.
Hooper SM, Westcott T, Evans PL, et al. Implant-supported facial prostheses provided by a maxillofacial unit in a U.K. regional hospital: Longevity and patient opinions. J Prosthodont. 2005;14(1):32-38.
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.
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