Subject: Facial Prostheses, External
Reviewed: September 23, 2013
This Clinical Policy Bulletin expresses our determination of whether certain services or supplies are medically necessary. We have reached these conclusions based on a review of currently available clinical information including:
We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.
Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.
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.
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||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.|
|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:
Original policy: November 4, 2004
Updated: September 25, 2006, August 26, 2008; November 16, 2009; January 20, 2011; June 5, 2012; September 23, 2013
Medical Policy Bulletin #0620: October 5, 2012
This CPB has been updated with additional references.
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.
*Current Procedural Terminology (CPT®) 2010 copyright
2010 American Medical Association. All Rights Reserved.