Prosthetics

Coverage

Documentation

Tips

Topic Details
 Bra/Camisole
  • LCD does not specify quantities of bras or camisoles that are covered. A physician determines what is reasonable and necessary on a case-by-case basis. Medical records should reflect and support what is ordered and dispensed to a beneficiary. Bras are a non-consumable item that fall under refill requirements and a supplier may only dispense a three-month quantity at one time
  • Bra - Mastectomy Bras, HCPCS L8000, L8001 and L8002 cannot be billed as an upgrade, even if bra is more expensive and may not be upgraded as the code definitions are not limited to a specific type of fabric, style, or cost, but rather, encompasses all fabrics, styles, and costs. The only HCPCS codes that can be billed as an upgrade in LCD are HCPCS L8031 and L8035. CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 120 describes an upgrade as "an item with features that go beyond what is medically necessary. An upgrade may include an excess component. An excess component may be an item, feature, or service, which is in addition to, or is more extensive and/or more expensive than item that is reasonable and necessary under Medicare's coverage requirements." A difference in price alone is not justification for an upgrade
  • Camisole - LCD indicates HCPCS L8015 is covered when a beneficiary uses this garment during postoperative period prior to being fitted with a permanent breast prosthesis, or wears garment as an alternative to mastectomy bras and breast prosthesis. A camisole may be covered for years after surgery as an alternative to a prosthesis and bra

Resource

  • External Breast Prostheses LCD
Cancelled Orders for Customized Items
Consolidated Billing
  • Under the consolidated billing requirement, a Skilled Nursing Facility (SNF) must submit all Medicare claims for services that its residents receive, except for specifically excluded services. View a list of those excluded services on the CMS SNF Consolidated Billing webpage. If code is on list, if can be billed directly to DME MAC by supplier
Items Billed Unassigned
  • Since upgrades are not allowed for bras or camisoles, a non-participating supplier can bill claims for bras and camisoles as unassigned. Beneficiary will be required to pay for bras when they are dispensed (at full price) and will receive reimbursement directly from Medicare for allowed amount; however, participating suppliers do not have this option, they must accept Medicare's allowed amount as payment in full
Item Provided Prior to Surgery
  • Do not provide items to a beneficiary before medical necessity has occurred. Per CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 120. "Medicare does not cover a prosthetic device dispensed to a patient prior to the time at which the patient undergoes the procedure that makes necessary the use of the device‚ĶMoreover, the need for the device cannot be clearly established until the procedure that makes its use possible is successfully performed." Delivery of DME may be within two days of anticipated discharge from a hospital or Skilled Nursing Facility (SNF) for fitting/training purposes, when discharge is to home. Date of service must be discharge date
Refills
  • Items such as socks and liners are considered non-consumable items and therefore may be treated as a refill item. If Detailed Written Order (DWO) identifies these items with quantity, frequency and number of refills, they may be dispensed as needed without obtaining a new order. For more information, see the Standard Documentation Language Policy Article for documentation requirements for refills of non-consumable supplies

 

Reviews/Audits

  • Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
     

Last Updated May 09, 2018

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.