Article Detail - JA DME

Medicare will cover a breast prosthesis and garments for a beneficiary who has had a mastectomy with a diagnosis code listed in Policy Article A52478. The quantity of covered bras and camisoles are not specified within the policy; that is determined by the physician. The medical records must support what is ordered and dispensed.

There are some items that are denied in this policy because they are deemed not reasonable and necessary:

L8031 - Silicone prosthesis with integral adhesive

L8033 - Nipple prosthesis, custom fabricated, reusable

L8035 - Custom mastectomy form

However, the items deemed not medically necessary (L8031, L8033, and L8035) may be billed as upgrades with the RT or LT modifier appended. View the Upgrades page on the Noridian Medicare website for billing information.