Breast Prostheses

Affected Providers

Physicians, non-physician practitioners, and suppliers who bill claims for breast prostheses.

HCPCS & CPT Codes

Local Coverage Determination (LCD): External Breast Prostheses (L33317) and Article: External Breast Prostheses (A52478) have the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for breast protheses is 25%, with a projected improper payment amount of $6.7 million.

We outline other policy requirements in:

• Article A52478
• LCD L33317
• Article: Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)

Denial Reasons

Insufficient documentation accounted for 50% of improper payments for breast prostheses during the 2024 reporting period, while medical necessity (14.4%) and other errors (35.6%) also caused improper payments. Other errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

Nationally Covered Indications

We cover a breast prosthesis for a patient who has had a mastectomy. Find the ICD-10-CM Codes that Support Medical Necessity section in Article A52478.

• We cover an external breast prosthesis garment with mastectomy form (HCPCS code L8015) used in the post-operative period before a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis.
• We cover a mastectomy bra (HCPCS code L8000) for a patient who has a covered mastectomy form (HCPCS code L8020) or silicone (or equal) breast prosthesis (HCPCS code L8030) when the pocket of the bra holds the form or prosthesis.

Nationally Non-Covered Indications

• Breast prostheses, silicone or equal, with integral adhesive (HCPCS code L8031) haven’t demonstrated a clinical advantage over those without the integral adhesive. If you bill L8031, we deny it as not reasonable and necessary.
• The medical necessity for the additional features of a custom fabricated prosthesis (HCPCS code L8035) compared with a prefabricated silicone breast prosthesis hasn’t been established, so, if you bill an L8035 breast prosthesis, we deny it as not reasonable and necessary.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.

Example of Improper Payments Due to Insufficient Documentation for Breast Prostheses

A supplier bills the claim for HCPCS code L8001 (Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type) and submits the following documentation per the review contractor’s request:

• Standard written order with correct HCPCS coding
• Treating practitioner’s medical record that doesn’t indicate the need for an integrated breast prosthesis form, unilaterally or bilaterally
• Proof of delivery

What Documentation Was Missing?

The doctor didn’t document the need for an integrated breast prosthesis form, unilaterally or bilaterally.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the Medicare Administrative Contractor recoups payment.

Recommendation

To prevent claim denials and improper payments, the certifying physician must collect and submit proper documentation, including specific information in the medical record detailing whether the patient needs an integrated breast prosthesis form.