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.
External Breast Prosthesis CriteriaA 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 ProsthesisReplacement 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