External Breast Prostheses: Supporting Medicare Beneficiaries

During Breast Cancer Awareness Month, we extend our support to suppliers offering essential services to those affected by this devastating disease. Medicare covers external breast prostheses for Medicare beneficiaries who meet the necessary criteria.

Robust medical documentation is critical in supporting the provision of external breast prostheses and related supplies.

Medicare coverage mandates that a patient's medical record must indicate a history of mastectomy and include a valid and complete order for coverage. This includes coverage for supplies both at the time of mastectomy and for ongoing needs.

Suppliers should refrain from submitting reimbursement claims until they receive a Standard Written Order (SWO). Additionally, the patient's medical record must contain information that justifies ongoing medical necessity. This information should be made available to the supplier or review contractor upon request.

The following types of documentation may substantiate the continued medical need for external breast prostheses and supplies:

  • A recent order from the treating physician for refills
  • The treating physician does not have to be the surgeon, and the order can address ongoing care not necessarily related to the mastectomy.
  • A recent prescription change.
  • Timely documentation in the beneficiary's medical record demonstrating the use of these items, as defined by a record entered within the preceding 12 months.
    • This documentation must indicate mastectomy or the absence of a breast.
    • In the absence of evidence of reconstruction, the original mastectomy surgery documentation is sufficient to verify the mastectomy.

Medicare guidelines typically determine the reasonable and useful lifetime of DME, orthotics, and certain prosthetics, with a minimum duration of five (5) years. However, external breast prostheses are an exception to this rule. The useful lifetime of silicone breast prostheses is 2 years, and fabric, foam, or fiber-filled breast prostheses, is 6 months. Nevertheless, a breast prosthesis may be replaced at any time if it is lost, irreparably damaged (excluding ordinary wear and tear), or if there is a change in the beneficiary's medical condition necessitating a different type of item.

By following these guidelines, you can ensure that Medicare beneficiaries receive the necessary support and that claims for external breast prostheses are processed correctly.

 

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