Breast Prosthesis and Bras Policy Number: PG0248 ADVANTAGE | ELITE | HMO Last Review: 08/14/2018

INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO

GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement.

SCOPE X Professional _ Facility

DESCRIPTION reconstruction has become an integral component of the treatment for patients with who have undergone a mastectomy or lumpectomy. External breast prostheses are available for women who have uneven- or unequal-sized 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 Breast Prosthesis and Mastectomy Bras do not require prior authorization but are subject to limits and coverage as listed below.

HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan Non-covered L8031, L8035

Advantage Non-covered A4280, L8001, L8002, L8031, L8032, L8039

COVERAGE CRITERIA HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage

Mastectomy bra (L8000, L8001, L8002)

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

PG0248 – 12/17/2020 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 bra (L8000, L8001, L8002) used to support the breast prosthesis is covered with a limit of 4 bras per year for HMO, PPO, Individual Marketplace & Elite/ProMedica Medicare Plan.

Mastectomy bra (L8000) used to support the breast prosthesis is covered with a limit of 4 bras per year for Advantage. L8001 & L8002 are non-covered for 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)

External breast prostheses (L8020, L8030) are covered post mastectomy and are limited to one type per affected side for all members. L8031 is non-covered 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.

Nipple prosthesis (L8032)

Nipple prosthesis (L8032) are non-covered for Advantage.

Nipple prosthesis (L8032) are covered with a limit of 4 per year for HMO, PPO, Individual Marketplace & Elite/ProMedica Medicare Plan. 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 covered with a limit of 1 per affected side per 2 year period for Advantage.

Custom breast prostheses (L8035) are non-covered for HMO, PPO, Individual Marketplace & Elite/ProMedica Medicare Plan.

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 Advantage.

PG0248 – 12/17/2020 Adhesive for use with breast prostheses (A4280) is allowed for HMO, PPO, Individual Marketplace & Elite/ProMedica Medicare Plan.

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

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, reusable, any type,each L8035 Custom breast prosthesis, post mastectomy, molded to patient model L8039 Breast prosthesis, not otherwise specified

REVISION HISTORY EXPLANATION ORIGINAL EFFECTIVE DATE: 09/01/2009 12/09/14: Policy updated to reflect most current clinical evidence per Medical Policy Steering Committee. 08/14/18: 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. 12/17/2020: Medical policy placed on the new Paramount Medical Policy Format

REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review Hayes, Inc.

PG0248 – 12/17/2020