Procedure Code
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Definition
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Less than or equal to 12 months post mastectomy.
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Greater than or equal to 13 months post mastectomy.
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L8000
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Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type
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- Up to four (4)
- Includes codes L8001, L8002, L8010, L8015, and S8460.
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- Up to two (2) every 12 months
- Includes codes L8001, L8002, L8010, L8015, and S8460.
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L8001
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Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type
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- Up to four (4)
- Includes codes L8000, L8002, L8010, L8015, and S8460.
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- Two (2) every 12 months
- Including codes L8000, L8002, L8010, L8015, and S8460.
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L8002
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Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type
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- Up to four (4)
- Includes codes L8000, L8001, L8010, L8015, and S8460.
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- Two (2) every 12 months
- Includes codes L8000, L8001, L8010, L8015, and S8460.
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L8010
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Breast prosthesis, mastectomy sleeve
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- Up to four (4)
- Includes codes L8000, L8001, L8002, L8015, and S8460.
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- Two (2) every 12 months
- Includes codes L8000, L8001, L8002, L8015, and S8460.
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L8015
|
External breast prosthesis garment, with mastectomy form, post mastectomy
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- Up to four (4)
- Includes codes L8000, L8001, L8002, L8010, and S8460.
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- Two (2) every 12 months
- Includes codes L8000, L8001, L8002, L8010, and S8460.
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L8020
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Breast prosthesis, mastectomy form
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- Two (2) within 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
- One (1) within 24 months for silicone prostheses per affected side.
- Includes codes L8030, L8031, L8032, L8035, and L8039.
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- Two (2) every 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
- One (1) every 24 months for silicone prostheses per affected side.
- Includes codes L8030, L8031, L8032, L8035, and L8039.
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L8030
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Breast prosthesis, silicone or equal, without integral adhesive
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- One (1) per affected side within 24 months
- Includes codes L8030 and L8035.
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- One (1) per affected side every 24 months,
- Includes codes L8030 and L8035.
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L8031
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Breast prosthesis, silicone or equal, with integral adhesive
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- One (1) per affected side within 24 months
- Includes codes L8030 and L8035.
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- One (1) per affected side every 24 months
- Includes codes L8030 and L8035.
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L8032
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Nipple prosthesis, reusable, any type, each
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- One (1) per affected side every three (3) months.
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- One (1) per affected side every three (3) months.
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L8035
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Custom breast prosthesis, post mastectomy, molded to individual model
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- Two (2) within 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
- One (1) within 24 months for silicone prostheses per affected side.
- Includes codes L8020, L8030, L8031, L8032, and L8039.
|
- Two (2) every 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
- One (1) every 24 months for silicone prostheses per affected side.
- Includes codes L8020, L8030, L8031, L8032, and L8039.
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L8039
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Breast prosthesis, not otherwise specified
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- Two (2) within 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
- One (1) within 24 months for silicone prostheses per affected side.
- Includes codes L8020, L8030, L8031, L8032, and L8035.
|
- Two (2) every 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
- One (1) every 24 months for silicone prostheses per affected side.
- Includes codes L8020, L8030, L8031, L8032, and L8035.
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A4280
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Adhesive skin support attachment for use with external breast prosthesis, each
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No quantity limits.
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No quantity limits.
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S8460
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Camisole, postmastectomy
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- Up to four (4)
- Includes codes L8000, L8001, L8002, L8010, and L8015.
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- Two (2) every 12 months
- Includes codes L8000, L8001, L8002, L8010, and L8015.
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