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 DME MAC 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.
Note: The following services and items are included in the allowance for a facial prosthesis and, therefore, are not separately reimbursed:
Modifications to a prosthesis are separately payable when they occur more than 90 days after delivery of the prosthesis and they are medically necessary because of a change in the member’s condition.
|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:|
|CPT codes covered if selection criteria are met:|
|21076||Impression and custom preparation; surgical obturator prosthesis|
|21079||interim obturator prosthesis|
|21080||definitive obturator prosthesis|
|21081||mandibular resection prosthesis|
|21082||palatal augmentation prosthesis|
|21083||palatal lift prosthesis|
|21085||oral surgical splint|
|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-10 codes covered is selection criteria are met (not all-inclusive):|
|Q11.1||Other anophthalmos [congenital absence of eye]|
|Q16.0||Congenital absence of (ear) auricle|
|Q16.9||Congenital malformation of ear causing impairment of hearing, unspecified [absence of ear, congenital]|
|Q17.8||Other specified congenital malformations of ear|
|Q18.8||Other specified congenital malformations of face and neck [loss of facial tissue]|
|Q30.1||Agenesis and underdevelopment of nose [absent nose]|
|Q67.0 - Q67.4||Congenital deformities of skull, face, and jaw [absence of facial tissue]|
|Z90.01||Acquired absence of eye|