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Breast Prosthesis ­ HealthPartners Care

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. Administrative Process

The purchase of an external breast prosthesis does not require prior authorization.

Coverage

External breast prostheses are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

1. 2. 3. 4. External breast prostheses are covered post mastectomy and are limited to one type per affected side. Mastectomy bra (L8000, L8001, L8002) used to support the breast prosthesis is covered. The limit is six per 12 month period. Adhesive skin support attachment (K0400) for use with external breast prosthesis when used in place of mastectomy support bras are covered. External breast prosthesis garment with mastectomy form (L8015) is covered immediately (within six months) post mastectomy. (An example is a "Softee"). These are limited to two and no replacements are covered. Replacements for external breast prostheses or forms will be determined according to the average life of the product, as established by the manufacturers - in most cases, limited to one per affected side per 12 month period. Replacement breast prosthesis or forms are covered when needed due to a change in a member's physical condition, including but not limited to, substantial weight gain or weight loss.

5.

6.

Indications that are not covered

Custom breast prostheses (L8035) are not covered because there is a standard model available which meets the medically necessary criteria.

Definitions

Breast prosthesis - a device or item worn externally that replaces a surgically removed breast.

Codes (This list may not be all inclusive)

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

L8000 - Breast prosthesis, mastectomy bra L8001 - Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral L8002 - Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral L8015 - External breast prosthesis garment, with mastectomy form, post mastectomy L8020 - Breast prosthesis, mastectomy form L8030 - Breast prosthesis, silicone or equal L8035 - Custom breast prosthesis, post mastectomy, molded to patient model L8039 - Breast prosthesis, not otherwise specified A4280 - Adhesive skin support attachment for use with external breast prosthesis, each S8460 - Camisole, post mastectomy

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Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

Items must be received from a contracted vendor for in-network benefits to apply. Number D011HPC-09; Approved Medical Director Committee 01/01/94; Revised 2/19/04, 8/5/09, 2/9/11; Annual Review 2/19/04, 6/1/05, 7/1/06, 8/1/07, 7/1/08, 8/5/09, 6/16/10, 2/2011, 2/2012.

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