Breast Prosthesis and Mastectomy Bras - Paramount Health Care

Medical Policy

Breast Prosthesis and Mastectomy Bras

Policy Number: PG0248

Last Review: 11/01/2022

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GUIDELINES:

? This policy does not certify benefits or authorization of benefits, which is designated by each individual

policyholder terms, conditions, exclusions, and limitations contract. It does not constitute a contract or

guarantee regarding coverage or reimbursement/payment. Self-Insured group specific policy will supersede

this general policy when group supplementary plan document or individual plan decision directs otherwise.

? Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy

and adherence to accepted national standards.

? This medical policy is solely for guiding medical necessity and explaining correct procedure reporting used to

assist in making coverage decisions and administering benefits.

? Durable Medical Equipment (DME) frequency limitations are calculated based on The Center for Medicare

and Medicaid Services (CMS) criteria and guidelines, National Coverage Determinations (NCD), and Local

Coverage Determinations (LCD) rules and regulations.

SCOPE:

X Professional

_ Facility

DESCRIPTION:

Breast reconstruction has become an integral component of the treatment for patients with breast cancer who

have undergone a mastectomy or lumpectomy. External breast prostheses are available for women who have

uneven- or unequal-sized breasts and who decide not to, or are waiting to, undergo surgical breast

reconstruction. They may choose to wear a breast prosthesis and mastectomy bra, or elect to wear a

mastectomy garment that has the prosthesis already inserted in it.

Prostheses can attach to the skin with a fabric backing and adhesive or may be worn unattached with a

mastectomy bra. Prefabricated prostheses come in various shapes, sizes and skin tones. Custom fabricated

prostheses are custom-designed and special ordered for the individual. These are usually patterned after a mold

that is taken of the breast and chest wall prior to surgery. In general, pre-fabricated prostheses can adequately

meet the external prosthetic needs of most individuals. Therefore, custom fabricated prosthetic garments would

not generally be considered medically necessary.

POLICY:

Paramount Commercial Insurance Plans and Elite (Medicare Advantage) Plans

Breast Prosthesis and Mastectomy Bras do not require prior authorization but are subject to limits and

coverage criteria as listed below.

Non-covered L8031, L8035

Paramount Advantage Medicaid

Non-covered

A4280, L8001, L8002, L8031, L8032, L8039

COVERAGE CRITERIA:

Paramount Commercial Insurance Plans and Elite (Medicare Advantage) Plans

Mastectomy bra (L8000, L8001, L8002)

Code L8000 describes a bra with pockets that are intended to hold a mastectomy form or breast prosthesis held

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adjacent to the chest wall. Bras coded L8000 do not include an integrated breast prosthesis (for bras with

integrated breast prosthesis, see codes L8001 and L8002). Products described by code L8000 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).

Codes L8001 and L8002 describe a bra with integrated breast prosthesis, either unilateral or bilateral,

respectively. Products described by codes L8001 and L8002 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).

Mastectomy bras (L8000, L8001, and L8002) used to support the breast prosthesis are covered with a limit of 4

bras per year for the Paramount Commercial Plans product lines.

Mastectomy bras (L8000, L8001, L8002) used to support the breast prosthesis are covered with no limits for

Medicare Advantage Plans product lines.

Mastectomy bra (L8000) used to support the breast prosthesis is covered with a limit of 4 bras per year for

Paramount Medicaid Advantage. L8001 & L8002 are non-covered for Paramount Medicaid Advantage.

External breast prosthesis garment with mastectomy form (L8015)

Code L8015 describes a camisole type undergarment with polyester fill used post mastectomy.

External breast prosthesis garment with mastectomy form (L8015) for use in the post-operative period prior to a

permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis is covered with a

limit of 3 per year for all members.

External breast prostheses (L8020, L8030, L8031)

External breast prostheses (L8020, L8030) are covered post mastectomy and are limited to one type per

affected side for all members.

Replacement breast prostheses (L8020, L8030) are covered when needed due to a change in a member¡¯s

physical condition, including but not limited to, substantial weight gain or weight loss. L8020 is limited to 2 per

affected side per year for all members. L8030 is limited to 1 per affected side per 2 year period for all members.

External breast prosthesis of a different type can be covered at any time if there is a change in the member¡¯s

medical condition necessitating a different type of item.

Breast prostheses, silicone or equal, with integral adhesive (L8031) have not been demonstrated to have a

clinical advantage over those without the integral adhesive. Therefore, L8031 will be considered not reasonable

and necessary.

Nipple prosthesis (L8032, L8033)

Nipple prosthesis (L8032 and L8033) are non-covered for Paramount Medicaid Advantage.

Nipple prosthesis (L8032 and L8033) are covered with a limit of 4 per year for Paramount Commercial Plans and

Medicare Advantage Plans.

Replacement sooner than the useful lifetime because of ordinary wear and tear will be denied as noncovered.

Breast prostheses (L8035, L8039)

Custom breast prostheses (L8035) are non-covered for the Paramount Commercial Plans and Medicare

Advantage Plans product lines. The additional features of a custom fabricated prosthesis (L8035) compared to

prefabricated silicone breast prosthesis have not been established and therefore will be denied as not medically

necessary.

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A custom fabricated breast prosthesis for initial use may be considered medically necessary for the Paramount

Medicaid Advantage product line when ALL the following criteria are met:

? The member has undergone a medically necessary mastectomy for breast cancer AND

? A moderate to severe thoracic cage deformity is present AND

? A standard breast prosthesis has been tried and proven to be an inadequate fit AND

? The attending physician/surgeon has documented in the medical records that a custom fabricated breast

prosthesis is the only suitable option

? Custom breast prostheses (L8035) are covered with a limit of 1 per affected side per 2 year period for

Paramount Medicaid Advantage.

Breast prosthesis not otherwise specified (L8039) will always be denied for invoice and documentation to

determine if the item is an upgrade, or if it is allowed under the prosthetic benefit.

Mastectomy sleeve (L8010)

Mastectomy sleeve (L8010) is covered with a limit of 3 per year for all members.

Adhesive for use with breast prostheses (A4280)

Adhesive for use with breast prostheses (A4280) is non-covered for Paramount Medicaid Advantage.

Adhesive for use with breast prostheses (A4280) is allowed for Paramount Commercial Plans and Medicare

Advantage Plans.

GENERAL DOCUMENTATION REQUIREMENTS

In order to justify payment for DME items, suppliers must meet the following requirements:

? Prescription (orders)

? Medical Record Information (including continued need/use if applicable)

? Correct Coding

? Proof of Delivery

An external breast prosthesis can be replaced at any time if it is either:

? Lost

? Irreparable damaged (does not include ordinary wear and tear)

A different type of external breast prosthesis may be covered at any time if there is a documented change in the

medial condition necessitating a different type of item.

CODING/BILLING INFORMATION:

The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered

may have selection criteria that must be met. Payment for supplies may be included in payment for other

services rendered.

CPT CODES

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

L8031

Breast prosthesis, silicone or equal, with integral adhesive

L8032

Nipple prosthesis, prefabricated, reusable, any type, each

L8033

Nipple prosthesis, custom fabricated, reusable, any material, any type, each

L8035

Custom breast prosthesis, post mastectomy, molded to patient model

L8039

Breast prosthesis, not otherwise specified

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REVISION HISTORY EXPLANATION: ORIGINAL EFFECTIVE DATE: 09/01/2009

Date

12/09/14

08/14/18

12/17/2020

11/01/2022

02/16/2023

03/29/2023

03/06/2024

Explanation & Changes

? Policy updated to reflect most current clinical evidence per Medical Policy Steering Committee

? Codes A4280 & L8032 are now covered for HMO, PPO, Individual Marketplace, Elite per CMS

guidelines

? Policy updated to reflect most current clinical evidence per Medical Policy Steering Committee

?

Medical policy placed on the new Paramount Medical Policy Format

? Policy updated to reflect most current clinical evidence

? Added procedure code L8033

? Removed coverage limits for mastectomy bras (L8000, L8001, L8002) for the Elite/ProMedica

Medicare Plan product lines, per CMS coverage determination

? Medical Policy updated to reflect Medicaid coverage to Anthem as of 02/01/2023

? Medical Policy updated to reflect DME limits calculated by CMS criteria/guidelines.

? Medical policy placed on the new Paramount Medical Policy Format

Paramount reserves the right to review and revise our policies periodically when necessary. When

there is an update, we will publish the most current policy to



REFERENCES/RESOURCES

Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and

services

American Medical Association, Current Procedural Terminology (CPT?) and associated publications and

services

Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS

Release and Code Sets

U.S. Preventive Services Task Force,

Industry Standard Review

Hayes, Inc.,

Industry Standard Review

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