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Auricular Prostheses
05.00.82

Policy

MEDICALLY NECESSARY

 
AURICULAR PROSTHESIS
An auricular prosthesis is considered medically necessary when any of the following criteria are met:

  • The individual has deformities and/or defects of the ear caused by trauma and/or accident
  • The individual has deformities and/or defects of the ear caused by disease or tumors/cancer
  • The individual has congenital or acquired physiologic deformities of the ear

Adhesives, adhesive remover, and tape are considered medically necessary when used in conjunction with an auricular prosthesis. 


REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the physician's office, hospital, nursing home, home health agencies, therapies, other health care professionals, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

 

STANDARD WRITTEN ORDER REQUIREMENTS

Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS

Medical record documentation must include a contemporaneously prepared delivery confirmation or member's receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)

The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately 7 days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual's medical record. Delivery of the supplies should not be done earlier than approximately 5 days before the individual would exhaust their on-hand supply.

For specified DME items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual's clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.​​


BILLING REQUIREMENTS


When codes A4450, A4452, and A5120 are used with a facial prosthesis, they must be billed with the AV modifier.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, auricular prostheses are covered under the medical benefits of the Company's products when the medical necessity criteria listed in the medical policy are met.

Description

An auricular prosthesis is a custom-made silicone-based product that helps restore a missing, disfigured, or malformed ear. There are a variety of methods of retention for auricular prostheses including medical- grade adhesives and bone anchorage using a titanium implant with either magnets, snaps, or clips. An auricular prosthesis can help to funnel sound into the ear canal.

References

Cedars Sinai. Silicone Ear Reconstruction for Microtia. [Cedars Sinai]. 2023. Available at: https://www.cedars-sinai.org/programs/microtia/patients/silicone-ear-reconstruction.html. Accessed April 01, 2024.


Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD) for Facial Prostheses (L33738). 01/01/2020 [CMS website]. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33 738&ver=18. Accessed April 01, 2024.


Centers for Medicare & Medicaid Services. Local Coverage Article (LCA) for Facial Prostheses – Policy Article (A52463). 01/01/2020 [CMS website]. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52463. Accessed April 01, 2024.


Children's Hospital of Philadelphia. Microtia. [Children's Hospital of Philadelphia]. 2022. Available at: https://www.chop.edu/conditions-diseases/microtia. Accessed April 01, 2024.


Company Benefit Contracts.​


Federspil PA. Auricular prostheses. Adv Otorhinolaryngol. 2010;68:65-80. doi: 10.1159/000314563. Epub 2010 May 3. PMID: 20442562.


Federspil PA. Auricular Prostheses in Microtia. Facial Plast Surg Clin North Am. 2018 Feb;26(1):97-104. doi: 10.1016/j.fsc.2017.09.007. PMID: 29153193.


International Anaplastology Association. Clinical anaplastology guidelines. [Internation Anaplastology Association].  May 2021. Available at: https://inaa.memberclicks.net/assets/docs/IAA Clinical Anaplastology Guidelines Version 3 May 2021.pdf. Accessed April 01, 2024.


Ozturk AN, Usumez A, Tosun Z. Implant-retained auricular prosthesis: a case report. Eur J Dent. 2010 Jan;4(1):71-4. Also available on the National Library of Medicine Web Site at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2798793/#b17-dent04_p0071. Accessed April 01, 2024.


Purves D, Augustine GJ, Fitzpatrick D, et al., editors. The External Ear. Neuroscience. 2nd edition. Sunderland (MA): Sinauer Associates; 2001. Available at: https://www.ncbi.nlm.nih.gov/books/NBK10908/#. Accessed April 01, 2024.


Ryan MA, Khoury T, Kaylie DM, Crowson MG, Brown CS, McClennen J, Raynor EM. Osseointegrated implants for auricular prostheses: An alternative to autologous repair. Laryngoscope. 2018 Sep;128(9):2153-2156. Also available on the National Library of Medicine Web Site at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109626/. Accessed April 01, 2024.


Tanveer W, Ridwan-Pramana A, Molinero-Mourelle P, Forouzanfar T. Applications of CAD/CAM Technology for Craniofacial Implants Placement and Manufacturing of Auricular Prostheses-Systematic Review. J Clin Med. 2023 Sep 13;12(18):5950.  Also available on the National Library of Medicine Web Site at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10532239/. Accessed April 01, 2024.


Tumblin M. Prosthetic ear general information. [Ear Community]. 2023. Available at: https://earcommunity.org/microtiaatresia/surgical-options/prosthetics/prosthetic-ear-information/. Accessed April 01, 2024.


Vanderbilt University Medical Center. Ear prosthesis. [The Microtia and Atresia Clinic at Vanderbilt]. 2023. Available at: https://microtiaandatresiacare.com/reconstructive-options/ear-prosthesis/. Accessed April 01, 2024.


Vijverberg MA, Verhamme L, van de Pol P, Kunst HPM, Mylanus EAM, Hol MKS. Auricular prostheses attached to osseointegrated implants: multidisciplinary work-up and clinical evaluation. Eur Arch Otorhinolaryngol. 2019 Apr;276(4):1017-1027. Also available on the National Library of Medicine Web Site at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6426806/. Accessed April 01, 2024.


Walsh WE, Dougherty B, Reisberg DJ, Applebaum EL, Shah C, O'Donnell P, Richter CP. The importance of auricular prostheses for speech recognition. Arch Facial Plast Surg. 2008 Sep-Oct;10(5):321-328. PMID: 18794410. Available at: https://pubmed.ncbi.nlm.nih.gov/18794410/. Accessed April 01, 2024.​

Coding

CPT Procedure Code Number(s)
21086
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
A4364 Adhesive, liquid or equal, any type, per oz

A4450 Tape, nonwaterproof, per 18 sq in

A4452 Tape, waterproof, per 18 sq in

A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per oz

A4456 Adhesive remover, wipes, any type, each

A5120 Skin barrier, wipes or swabs, each

L8045     Auricular prosthesis, provided by a nonphysician​
Revenue Code Number(s)
N/A

MODIFIERS

AV - Item furnished in conjunction with a prosthetic device, prosthetic or orthotic

Coding and Billing Requirements

MODIFIERS

AV - Item furnished in conjunction with a prosthetic device, prosthetic or orthotic​

Policy History

5/20/2024
5/20/2024
05.00.82
Medical Policy Bulletin
Commercial
No
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.