OAR 410-122-0655: External Breast Prostheses

(1) Indications and Limitations of Coverage and Medical Appropriateness: (a) The Division may cover an external breast prosthesis for a client who has had a mastectomy; (b) An external breast prosthesis garment, with mastectomy form (L8015) may be covered for use in the postoperative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis; (c) An external breast prosthesis of a different type may be covered if there is a change in the client’s medical condition necessitating a different type of item; (d) The Division will pay for only one breast prosthesis per side for the useful lifetime of the prosthesis; (e) The Division will pay for a breast prosthesis for a client residing in a nursing facility; (f) Two prostheses, one per side, are allowed for a client who has had bilateral mastectomies; (g) More than one external breast prosthesis per side is not covered; (h) An external breast prosthesis of the same type may be replaced if it is lost or is irreparably damaged (this does not include ordinary wear and tear); (i) Replacement sooner than the useful lifetime because of ordinary wear and tear is not covered. (2) Guidelines: (a) Use code A4280 when billing for an adhesive skin support that attaches an external breast prosthesis directly to the chest wall; (b) L8000 is limited to a maximum of four units every 12 months; (c) Code L8015 describes a camisole type undergarment with polyester fill used post mastectomy; (d) The right (RT) and left (LT) modifiers must be used with these codes. When the same code for two breast prostheses are billed for both breasts on the same date, the items (RT and LT) must be entered on the same line of the claim form using the RTLT modifier and two units of service; (e) The useful lifetime expectancy for silicone breast prostheses is two years; (f) For fabric, foam, or fiber filled breast prostheses, the useful lifetime expectancy is six months. (3) Requirements: (a) For services that do not require prior authorization (PA), the durable medical equipment, prosthetic, orthotic and supplies (DMEPOS) provider must have documentation on file which supports conditions of coverage as specified in this rule are met; (b) For services that require PA, the DMEPOS provider must submit documentation for review which supports conditions of coverage as specified in this rule are met; (c) Medical records must be made available to the Division on request. (4) Table 122-0655 (Procedure Codes): The procedure codes in this table may be covered for purchase. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]