OAR 410-122-0680: Facial Prostheses

(1) Indications and Coverage: (a) Covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect; (b) Adhesives, adhesive remover and tape used in conjunction with a facial prosthesis are covered. Other skin care products related to the prosthesis, including but not limited to cosmetics, skin cream, cleansers, etc., are not covered; (c) The following services and items are included in the allowance for a facial prosthesis: (A) Evaluation of the client; (B) Pre-operative planning; (C) Cost of materials; (D) Labor involved in the fabrication and fitting of the prosthesis; (E) Modifications to the prosthesis made at the time of delivery of the prosthesis or within 90 days thereafter; (F) Repair due to normal wear or tear within 90 days of delivery; (G) Follow-up visits within 90 days of delivery of the prosthesis; (d) Modifications to a prosthesis that occur more than 90 days after delivery of the prosthesis and that are required because of a change in the client’s condition are covered; (e) Repairs are covered when there has been accidental damage or extensive wear to the prosthesis that can be repaired. If the expense for repairs exceeds the estimated expense for a replacement prosthesis, no payments can be made for the amount of the excess; (f) Follow-up visits which occur more than 90 days after delivery and which do not involve modification or repair of the prosthesis are non-covered services; (g) Replacement of a facial prosthesis is covered in cases of loss or irreparable damage or wear or when required because of a change in the client’s condition that cannot be accommodated by modification of the existing prosthesis; (h) When a prosthesis is needed for adjacent facial regions, a single code must be used to bill for the item, whenever possible. For example, if a defect involves the nose and orbit, this should be billed using the hemi-facial prosthesis code and not separate codes for the orbit and nose. This would apply even if the prosthesis is fabricated in two separate parts. (2) Documentation: The following must be submitted for prior authorization (PA): (a) An order for the initial prosthesis and/or related supplies which is signed and dated by the ordering prescribing practitioner must be kept on file by the prosthetist/supplier and submitted with request for PA; (b) A separate prescribing practitioner order is not required for subsequent modifications, repairs or replacement of a facial prosthesis; (c) A new prescribing practitioner order is required when different supplies are ordered; (d) A photograph of the prosthesis and a photograph of the client without the prosthesis must be retained in the supplier’s record and must be submitted with the PA request; (e) When code L8048 is used for a miscellaneous prosthesis or prosthetic component, the authorization request must be accompanied by a clear description and a drawing/copy of photograph of the item provided and the medical appropriateness; (f) Requests for replacement, repair or modification of a facial prosthesis must include an explanation of the reason for the service; (g) When replacement involves a new impression/moulage rather than use of a previous master model, the reason for the new impression/moulage must be clearly documented in the authorization request. (3) Procedure Codes — Table 122-0680. [ED. NOTE: Tables referenced are available from the agency.] [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]