Clinicians! Are You Ordering External Breast Prostheses and Supplies for Your Patient?

Following this guidance will help your patients and the Medicare program by verifying there is medical documentation to support the provision of external breast prostheses and supplies.

Medicare coverage requires the patient's medical record to show a past mastectomy and a valid and complete order. Coverage includes supplies both at the time of the mastectomy and after.

The DMEPOS supplier must have a verbal/dispensing/preliminary order prior to providing the prostheses and /or supplies. The supplier cannot submit a claim for reimbursement until you supply a detailed written order. The detailed written order must contain the elements in the chart below. Help your patient by providing this timely.

There must also be information in the patient's medical record that justifies continued medical need and it must be made available to the supplier or review contractor upon request.

The following may serve as documentation justifying continued medical need for the External Breast Prostheses and supplies:

  • A recent order by the treating clinician for refills
    • Does not have to be the surgeon
    • Current treatment not necessarily related to the mastectomy, however addressing on-going care
  • A recent change in prescription
  • Timely documentation in beneficiary's medical record showing usage of item(s)
    • Defined as a record entered in preceding 12 months
    • Must indicate mastectomy or absence of breast
    • In absence of evidence of reconstruction, original mastectomy surgery documentation is sufficient to verify mastectomy
DWO elements prior to billing For periodic items (i.e., bras) DWO must also include:
Beneficiary's name Item(s) to be dispensed
Prescribing practitioner's name Frequency (how often are bras to be dispensed)
Date of the order Quantity to be dispensed (number of bras)
Detailed description of the item(s) Number of refills
Prescribing practitioner's signature and signature date  

 

For coverage and limitations of these supplies review Local Coverage Determination (LCD) L33317 and Policy Article A52478.

LCD for External Breast Prostheses can be located at the following:

  • Jurisdiction A - CT, DE, MA, ME, MD, NH, NJ, NY, PA, RI, VT, Washington D.C.
  • Jurisdiction B - Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin
  • Jurisdiction C - Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia
  • Jurisdiction D - Am. Samoa, Guam, N. Mariana Is., AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY

 

Last Updated Aug 23, 2018