External Breast Prosthesis
Number: 0097
Policy
Aetna considers medically necessary an external breast prosthesis following a medically necessary mastectomy or for persons with gender dysphoria. In addition, up to 4 post-mastectomy bras are considered medically necessary initially following a medically necessary mastectomy or for persons with gender dysphoria 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 or for persons with gender dysphoria. For persons who have had a 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 persons with gender dysphoria, and 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 is 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 and for persons with gender dysphoria. 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 gradient compression lymphedema sleeves ("mastectomy sleeves") medically necessary initially per affected arm, then two replacements every six months. Note: The Women's Health and Cancer Rights Act (WHCRA) of 1998 (Public Law #105-277) mandates that all insurance companies provide coverage for "prostheses and physical complications of mastectomy including lymphedemas."
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).
"Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type" and "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 model" describes 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.
| Code | Code Description |
|---|---|
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: |
|
| 19300-19303 19305-19307 |
Mastectomy procedures |
HCPCS codes covered if selection criteria are met: |
|
| A4280 | Adhesive skin support attachment for use with external breast prosthesis, each |
| A6549 | Gradient compression stocking/sleeve, not otherwise specified |
| 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, prefabricated, reusable, any type, each |
| L8033 | Nipple prosthesis, custom fabricated, reusable, any material, any type, each |
| L8039 | Breast prosthesis, not otherwise specified |
| S8422 | Gradient pressure aid (sleeve), custom made, medium weight |
| S8423 | Gradient pressure aid (sleeve), custom made, heavy weight |
| S8424 | Gradient pressure aid (sleeve), ready made |
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 |
| F64.0 - F64.9 | Gender identity disorders [gender dysphoria] |
| N60.11 - N60.19 | Diffuse cystic mastopathy [severe fibrocystic disease] |
| Z85.3 | Personal history of malignant neoplasm of breast |
| Z90.10 - Z90.13 | Acquired absence of breast and nipple |
The above policy is based on the following references:
- 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.
- Glaus SW, Carlson GW. Long-term role of external breast prostheses after total mastectomy. Breast J. 2009;15(4):385-393.
- Handel N. Current status of breast reconstruction after mastectomy. Oncology (Huntingt). 1991;5(11):73-84, 89, 90, 92.
- Hojan K, Manikowska F, Chen BP, Lin CC. The influence of an external breast prosthesis on the posture of women after mastectomy. J Back Musculoskelet Rehabil. 2016;29(2):337-342.
- Hojan K, Manikowska F, Molinska-Glura M, et al. The impact of an external breast prosthesis on the gait parameters of women after mastectomy. Cancer Nurs. 2014;37(2):E30-E36.
- Hojan K, Manikowska F. Can the weight of an external breast prosthesis influence trunk biomechanics during functional movement in postmastectomy women? Biomed Res Int. 2017;2017:9867694.
- Jetha ZA, Gul RB, Lalani S, et al. Women experiences of using external breast prosthesis after mastectomy. Asia Pac J Oncol Nurs. 2017;4(3):250-258.
- 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.
- Nahabedian M. Breast reconstruction: Prosthetic devices. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed December 2015.
- 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.
- 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.
- 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.
- Reaby LL. Breast restoration decision making: Enhancing the process. Cancer Nurs. 1998;21(3):196-204.
- 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.
- 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.
- Snyderman RK. Alternatives in reconstructive surgery after mastectomy. Cancer. 1980;46(4 Suppl):1053-1058.
- 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.
- van Dam FS, Bergman RB. Psychosocial and surgical aspects of breast reconstruction. Eur J Surg Oncol. 1988;14(2):141-149.
