Please note that this criteria is taken and summarized directly from Noridian Medicare's LCD page. We try to keep this updated as possible. For the full article, please click here.
Previous PageInstructions

External Breast Prosthesis Criteria

A breast prosthesis is covered for a patient who has had a mastectomy.

A mastectomy bra (L8000) is covered for a patient who has a covered mastectomy form (L8020) or silicone (or equal) breast prosthesis (L8030) when the pocket of the bra is used to hold the form/prosthesis.

Qualifying ICD-10s to use on the prescription:
      Z85.3, Z90.10, C50.019 C50.919, C79.81, D05.90 or I97.2
      Must use these specific ICD-10’s for Left, Right, or Bilateral

Replacement of External Breast Prosthesis

Replacement for the same type is required due to loss or irreparable accidental damage

Replacement for a different type is required due to a significant change in the patient’s medical condition

Patient’s medical records* support that the device is still medically necessary

Supplier’s record documents the reason for the replacement