Medicare Advantage

Medical Policy

Title:

External Breast Prostheses

Policy #:

MA05.033f

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

MEDICALLY NECESSARY

A breast prosthesis is considered medically necessary and, therefore, covered for an individual who has had a mastectomy.

An external breast prosthesis garment, with mastectomy form (L8015), is considered medically necessary and, therefore, covered for use in the postoperative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis.

A mastectomy bra (L8000) is considered medically necessary and, therefore, covered for an individual who has a covered mastectomy form (L8020) or silicone (or equal) breast prosthesis (L8030) when the pocket of the bra is used to hold the form/prosthesis.

NOT MEDICALLY NECESSARY

An external breast prosthesis of the same type can be replaced at any time if it is lost or is irreparably damaged (this does not include ordinary wear and tear). An external breast prosthesis of a different type can be covered at any time if there is a change in the individual's medical condition necessitating a different type of item. The Company will pay for only one breast prosthesis per side for the useful lifetime of the prosthesis. Two prostheses, one per side, are allowed for those persons who have had bilateral mastectomies. More than one external breast prosthesis per side is considered not medically necessary and, therefore, not covered.

Breast prostheses, silicone or equal, with integral adhesive (L8031) have not been demonstrated to have a clinical advantage over those without the integral adhesive. Therefore, these items are considered not medically necessary and, therefore, not covered.

A custom-fabricated prosthesis (L8035) is considered not medically necessary and, therefore, not covered because the medical necessity for the additional features of a custom-fabricated prosthesis (L8035) compared with a prefabricated

silicone breast prosthesis has not been established.

NOT COVERED

A mastectomy sleeve is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

The useful lifetime expectancy for silicone breast prostheses is 2 years. The useful lifetime expectancy for a nipple prostheses is 3 months. For fabric, foam, or fiber-filled breast prostheses, the useful lifetime expectancy is 6 months. Replacement sooner than the useful lifetime because of ordinary wear and tear is noncovered.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

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 (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 30 calendar 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 10 calendar days before the individual would exhaust their supply.

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

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Claims submitted for billing will need to be reported using appropriate coding representing the most specific condition and laterality.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, an external breast prosthesis is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

An external breast prosthesis is an artificial breast form that can be worn after a mastectomy. It is made from several different types of material (e.g., silicone gel, foam, and fiberfill) that are of similar weight and feel to natural breast tissue. Some prostheses adhere directly to the chest area, while others fit into pockets of mastectomy bras to hold the prosthesis in place.

References

Evidence of Coverage.

Noridian Healthcare Solutions. Local Coverage Article (A52478): External breast prostheses. Original: 10/01/2015. (Revised: 10/01/2025). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52478. Accessed October 13, 2025.

Noridian Healthcare Solutions. Local Coverage Determination (LCD)(L33317): External breast prostheses. Original: 10/01/2015. (Revised: 04/01/2025). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33317. Accessed October 13, 2025.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

A BREAST PROSTHESIS IS MEDICALLY NECESSARY FOR AN INDIVIDUAL WHO HAS HAD A MASTECTOMY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES

C50.011 Malignant neoplasm of nipple and areola, right female breast

C50.012 Malignant neoplasm of nipple and areola, left female breast

C50.111 Malignant neoplasm of central portion of right female breast

C50.112 Malignant neoplasm of central portion of left female breast

C50.211 Malignant neoplasm of upper-inner quadrant of right female breast

C50.212 Malignant neoplasm of upper-inner quadrant of left female breast

C50.311 Malignant neoplasm of lower-inner quadrant of right female breast

C50.312 Malignant neoplasm of lower-inner quadrant of left female breast

C50.411 Malignant neoplasm of upper-outer quadrant of right female breast

C50.412 Malignant neoplasm of upper-outer quadrant of left female breast

C50.511 Malignant neoplasm of lower-outer quadrant of right female breast

C50.512 Malignant neoplasm of lower-outer quadrant of left female breast

C50.611 Malignant neoplasm of axillary tail of right female breast

C50.612 Malignant neoplasm of axillary tail of left female breast

C50.811 Malignant neoplasm of overlapping sites of right female breast

C50.812 Malignant neoplasm of overlapping sites of left female breast

C50.911 Malignant neoplasm of unspecified site of right female breast

C50.912 Malignant neoplasm of unspecified site of left female breast

C50.A1 Malignant inflammatory neoplasm of right breast

C50.A2 Malignant inflammatory neoplasm of left breast

C79.81 Secondary malignant neoplasm of breast

D05.01 Lobular carcinoma in situ of right breast

D05.02 Lobular carcinoma in situ of left breast

D05.11 Intraductal carcinoma in situ of right breast

D05.12 Intraductal carcinoma in situ of left breast

D05.81 Other specified type of carcinoma in situ of right breast

D05.82 Other specified type of carcinoma in situ of left breast

D05.91 Unspecified type of carcinoma in situ of right breast

D05.92 Unspecified type of carcinoma in situ of left breast

I97.2 Postmastectomy lymphedema syndrome

Z85.3 Personal history of malignant neoplasm of breast

Z90.11 Acquired absence of right breast and nipple

Z90.12 Acquired absence of left breast and nipple

Z90.13 Acquired absence of bilateral breasts and nipples

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY

A4280 Adhesive skin support attachment for use with external breast prosthesis, each

L8000 Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type

L8001 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type

L8002 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type

L8015 External breast prosthesis garment, with mastectomy form, post mastectomy

L8020 Breast prosthesis, mastectomy form

L8030 Breast prosthesis, silicone or equal, without integral adhesive, any type

L8032 Nipple prosthesis, prefabricated, reusable, any type, each

L8039 Breast prosthesis, not otherwise specified

NOT MEDICALLY NECESSARY

L8031 Breast prosthesis, silicone or equal, with integral adhesive, any type

L8033 Nipple prosthesis, custom fabricated, reusable, any material, any type, each

L8035 Custom breast prosthesis, post mastectomy, molded to patient model, any type

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

HCPCS code L8000 describes a bra with pockets that are intended to hold a mastectomy form or breast prosthesis held adjacent to the chest wall. Bras coded L8000 do not include an integrated breast prosthesis (for bras with integrated breast prosthesis, see codes L8001 and L8002). Products described by code L8000 may be constructed of any material (e.g., cotton, polyester, or other materials), with any type or location of closure, any size, with or without integrated structural support (e.g., underwire).

HCPCS codes L8001 and L8002 describe a bra with integrated breast prosthesis, either unilateral or bilateral. Products described by codes L8001 and L8002 may be constructed of any material (e.g., cotton, polyester, or other materials) with any type or location of closure, any size, with or without integrated structural support (e.g., underwire).

HCPCS code L8015 describes a camisole-type undergarment with polyester fill used post-mastectomy.

A custom-fabricated prosthesis is one which is individually made for a specific patient starting with basic materials. HCPCS code L8035 describes a molded-to-patient-model custom breast prosthesis. It is a particular type of custom-fabricated prosthesis in which an impression is made of the chest wall, and this impression is then used to make a positive model of the chest wall. The prosthesis is then molded on this positive model.

HCPCS code A4280 should be used when billing for an adhesive skin support that attaches an external breast prosthesis directly to the chest wall.

Cross Reference

Policy History

Revisions From MA05.033f:

10/01/2026

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified for the HCPCS code update, effective 10/01/2026.

The following HCPCS codes have been revised:

L8030 Breast prosthesis, silicone or equal, without integral adhesive, any type
L8031 Breast prosthesis, silicone or equal, with integral adhesive, any type
L8035 Custom breast prosthesis, post mastectomy, molded to patient model, any type

Revisions From MA05.033e:

05/27/2026	This policy has been reissued in accordance with the Company's annual review process.
10/01/2025	This version of the policy is published on 11/17/2025; however, it will be retroactively effective on 10/1/2025. The intent of this policy remains unchanged, but the policy has been updated to add the following ICD-10 CM codes in accordance with Medicare to the policy: C50.A1 Malignant inflammatory neoplasm of right breast C50.A2 Malignant inflammatory neoplasm of left breast

05/27/2026

This policy has been reissued in accordance with the Company's annual review process.

10/01/2025

This version of the policy is published on 11/17/2025; however, it will be retroactively effective on 10/1/2025.

The intent of this policy remains unchanged, but the policy has been updated to add the
following ICD-10 CM codes in accordance with Medicare to the policy:

C50.A1 Malignant inflammatory neoplasm of right breast

C50.A2 Malignant inflammatory neoplasm of left breast

Revisions From MA05.033d:

04/02/2025

This policy has been reissued in accordance with the Company's annual review process

04/01/2025

This policy has been identified and updated for the HCPCS code update effective 04/01/2025.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following HCPCS code has been deleted from the policy:
L8010 Breast prosthesis, mastectomy sleeve

Revisions From MA05.033c:

05/20/2024

This version of the policy will become effective 05/20/2024.

In accordance with Medicare, the timelines for refill requirements were revised.

The following ICD-10 CM codes have been deleted from this policy: C50.019, C50.119, C50.219, C50.319, C50.419, C50.519, C50.619, C50.819, C50.919, D05.00, D05.10, D05.80, D05.90, and Z90.10.

Revisions From MA05.033b:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
04/05/2023	The policy has been reviewed and reissued to communicate the Company's continuing position on External Breast Prostheses.
05/18/2022	The policy has been reviewed and reissued to communicate the Company’s continuing position on External Breast Prostheses.
02/24/2021	The policy has been reviewed and reissued to communicate the Company’s continuing position on External Breast Prostheses.
02/26/2020	This policy has been reissued in accordance with the Company's annual review process.
01/01/2020	This policy has been identified for the annual HCPCS code update effective 01/01/2020. The following HCPCS code has been revised in this policy: Changed from: L8032 Nipple prosthesis, reusable, any type, each Changed to: L8032 Nipple prosthesis, prefabricated, reusable, any type, each The following HCPCS code has been added to this policy as not medically necessary: L8033 Nipple prosthesis, custom fabricated, reusable, any material, any type, each

Revisions From MA05.033a:

02/13/2019	This policy has been reissued in accordance with the Company's annual review process.
02/07/2018	This version of the policy will become effective 02/07/2018. Revised policy number MA05.033a was issued as a result of the department's annual review process to communicate the Company’s continuing position on External Breast prostheses.

Revisions From MA05.033:

02/15/2017	The policy has been reviewed and reissued to communicate the Company’s continuing position on External Breast prostheses. Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.
02/03/2016	The policy has been reviewed and reissued to communicate the Company’s continuing position on External Breast prostheses. Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.
06/24/2015	The policy has been reviewed and reissued to communicate the Company’s continuing position on External Breast prostheses. Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.
01/01/2015	This is a new policy.

Version Effective Date:

10/1/2026

Version Issued Date: