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L8000 |
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Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type
| short | Mastectomy bra |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 6.0 | 3 Date of Service Edit: Clinical | Clinical: Data | | DME | 6.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L8001 |
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Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type
| short | Breast prosthesis bra & form |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data | | DME | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L8002 |
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Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type
| short | Brst prsth bra & bilat form |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data | | DME | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L8010 |
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Breast prosthesis, mastectomy sleeve
| short | Mastectomy sleeve |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data | | DME | 0.0 | 3 Date of Service Edit: Clinical | Published Contractor Policy |
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L8015 |
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External breast prosthesis garment, with mastectomy form, post mastectomy
| short | Ext breastprosthesis garment |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data | | DME | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L8020 |
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Breast prosthesis, mastectomy form
| short | Mastectomy form |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data | | DME | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L8030 |
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Breast prosthesis, silicone or equal, without integral adhesive
| short | Breast prosthes w/o adhesive |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration | | DME | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
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L8031 |
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Breast prosthesis, silicone or equal, with integral adhesive
| short | Breast prosthesis w adhesive |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration | | DME | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
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L8032 |
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Nipple prosthesis, prefabricated, reusable, any type, each
| short | Reusable nipple prosthesis |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L8033 |
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Nipple prosthesis, custom fabricated, reusable, any material, any type, each
| short | Nipple prosthesis custom, ea |
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L8035 |
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Custom breast prosthesis, post mastectomy, molded to patient model
| short | Custom breast prosthesis |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration | | DME | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
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L8039 |
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Breast prosthesis, not otherwise specified
| short | Breast prosthesis nos |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration | | DME | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
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