Facial Prostheses - Policy Article

**NONMEDICAL NECESSITY COVERAGE AND PAYMENT RULES**  
  
For any item to be covered by Medicare, it must 1) be eligible for a defined
Medicare benefit category, 2) be reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a malformed
body member, and 3) meet all other applicable Medicare statutory and
regulatory requirements. Information provided in this policy article relates
to determinations other than those based on Social Security Act 1862(a)(1)(A)
provisions (i.e. "reasonable and necessary").

Facial prostheses are covered under the Medicare Artificial Legs, Arms and
Eyes benefit (Social Security Act 1861(s)(9)). In order for a beneficiary to
be eligible for reimbursement, the reasonable and necessary (R&N) requirements
set out in the related Local Coverage Determination must be met. In addition
to meeting the benefit policy, there are specific statutory payment policy
requirements, discussed below, that also must be met.

Adhesives, adhesive remover, skin barrier wipes, and tape used in conjunction
with a facial prosthesis are covered.

The following services and items are included in the allowance for a facial
prosthesis and, therefore, are not separately billable to or payable by
Medicare under the prosthetic device benefit:

  * Evaluation of the beneficiary

  * Pre-operative planning

  * Cost of materials

  * Labor involved in the fabrication and fitting of the prosthesis

  * Modifications to the prosthesis made at the time delivery of the prosthesis or within 90 days thereafter

  * Repair due to normal wear or tear within 90 days of delivery

  * Follow-up visits within 90 days of delivery of the prosthesis

Claims for implanted components (e.g., titanium studs, magnets, etc.) and
procedures used to affix the external facial prosthesis to the beneficiary are
not the jurisdiction of the DME MAC. Claims for these items and services will
be denied as wrong jurisdiction.

Modifications to a prosthesis are separately payable when they occur more than
90 days after delivery of the prosthesis and they are required because of a
change in the beneficiary's condition.

Repairs are covered when there has been accidental damage or extensive wear to
the prosthesis that can be repaired. If the expense for repairs exceeds the
estimated expense for a replacement prosthesis, no payments can be made for
the amount of the excess.

Follow-up visits which occur more than 90 days after delivery and which do not
involve modification or repair of the prosthesis are noncovered services.

Replacement of a facial prosthesis is covered in cases of loss or irreparable
damage or wear or when required because of a change in the beneficiary's
condition that cannot be accommodated by modification of the existing
prosthesis. When replacement involves a new impression/moulage rather than use
of a previous master model, the reason for the new impression/moulage must be
clearly documented in the supplier's records and available upon request.

Claims for facial prostheses from nonphysicians provided in an office or
nursing home setting are submitted to the DME MAC. Claims for facial
prostheses from physicians in these settings are submitted to the local
carrier. Claims for facial prostheses provided in an outpatient hospital
setting are submitted to the local intermediary. Facial prostheses provided in
an inpatient hospital setting are included in the payment made to the
hospital; and, therefore should not be submitted to the DME MAC. Implanted
prosthesis anchoring components should not be billed to the DME MAC.

If an ocular prosthesis is dispensed to the beneficiary as an integral part of
a facial prosthesis, the ocular prosthesis component must be billed by the
supplier of the facial prosthesis. (For information on ocular prostheses that
are not part of orbital prostheses, refer to the Eye Prostheses LCD.)

Skin care products related to the prosthesis, including but not limited to
cosmetics, skin cream, cleansers, etc., are noncovered.

Claims for tape and adhesive (A4450, A4452, A5120) that are billed without an
AV modifier or another modifier indicating coverage under a different policy
will be rejected as missing information.



**REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed.
Reg Vol 217)**

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a
Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the
DME MACs provide a list of the specified codes, which is periodically updated.
The required Face-to-Face Encounter and Written Order Prior to Delivery List
is available [here](https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-
Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment).

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol
217) that do not meet the face-to-face encounter and WOPD requirements
specified in the LCD-related Standard Documentation Requirements Article
(A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied
as not reasonable and necessary. If the WOPD is not obtained prior to
delivery, payment will not be made for that item even if a WOPD is
subsequently obtained by the supplier. If a similar item is subsequently
provided by an unrelated supplier who has obtained a WOPD prior to delivery,
it will be eligible for coverage.



**POLICY SPECIFIC DOCUMENTATION REQUIREMENTS  
  
** In addition to policy specific documentation requirements, there are
general documentation requirements that are applicable to all DMEPOS policies.
These general requirements are located in the DOCUMENTATION REQUIREMENTS
section of the LCD.

Refer to the LCD-related Standard Documentation Requirements article, located
at the bottom of this Policy Article under the Related Local Coverage
Documents section for additional information regarding GENERAL DOCUMENTATION
REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.

When either code V2629 or L8048 is billed, the claim must be accompanied by a
brief description of the item in the narrative field. When L8048 is provided,
a drawing/photograph of the item provided must be available upon request.

The treating practitioner's records must contain information which supports
the medical necessity of the item ordered. The prosthetist's documentation of
the necessity for a replacement prosthesis is appropriate documentation for
that claim if the replacement is necessitated by other than medical reasons.

MODIFIERS

AV, KM, KN, RT and LT MODIFIERS:

Claims for tape and adhesive (A4450, A4452, A5120) that are submitted without
AV modifier will be rejected as missing information.

When a replacement prosthesis is fabricated starting with a new
impression/moulage, the KM modifier should be added to the code. When a
replacement prosthesis is fabricated using a previous master model, the KN
modifier should be added to the code.

The right (RT) and/or left (LT) modifiers must be used with facial prosthesis
codes when applicable. Effective for claims with dates of service (DOS) on or
after 3/1/2019, if bilateral prostheses using the same code are billed on the
same date of service, bill each item on two separate claim lines using the RT
and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use
the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed
with codes L8042, L8043 and L8045, L8046, without modifiers RT and/or LT, or
with RTLT on the same claim line and 2 UOS, will be rejected as incorrect
coding.

**CODING GUIDELINES**

Codes for a facial prosthesis (L8040, L8041, L8042, L8043, L8044, L8045,
L8046, L8047) describe a complete prosthesis, except as noted below for the
use of code L8048 (UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT, PROVIDED
BY A NON-PHYSICIAN).  

A nasal prosthesis (L8040) is a removable superficial prosthesis, which
restores all or part of the nose. It may include the nasal septum.

A midfacial prosthesis (L8041) is a removable superficial prosthesis, which
restores part or all of the nose plus significant adjacent facial
tissue/structures, but does not include the orbit or any intraoral maxillary
component. Adjacent facial tissue/structures include one or more of the
following: soft tissue of the cheek, upper lip, or forehead.

An orbital prosthesis (L8042) is a removable superficial prosthesis, which
restores the eyelids and the hard and soft tissue of the orbit. It may also
include the eyebrow. This code does not include the ocular prosthesis
component.

An upper facial prosthesis (L8043) is a removable superficial prosthesis,
which restores the orbit plus significant adjacent facial tissue/structures,
but does not include the nose or any intraoral maxillary component. Adjacent
facial tissue/structures include one or more of the following: soft tissue of
the cheek or forehead. This code does not include the ocular prosthesis
component.

A hemi-facial prosthesis (L8044) is a removable superficial prosthesis, which
restores part or all of the nose plus the orbit plus significant adjacent
facial tissue/structures, but does not include any intraoral maxillary
component. This code does not include the ocular prosthesis component.

An auricular prosthesis (L8045) is a removable superficial prosthesis, which
restores all or part of the ear.

A partial facial prosthesis (L8046) is a removable superficial prosthesis
which restores a portion of the face but which does not specifically involve
the nose, orbit, or ear.

A nasal septal prosthesis (L8047) is a removable prosthesis, which occludes a
hole in the nasal septum but does not include superficial nasal tissue.

Code L8048 is a miscellaneous code. There are limited scenarios where the use
of miscellaneous code L8048 is appropriate:

  1. If a facial prosthesis is not described by a specific code, L8040, L8041, L8042, L8043, L8044, L8045, L8046, or L8047.

  2. If a facial prosthesis has a component which is used to attach it to a bone-anchored implant or to an internal prosthesis (e.g., maxillary obturator), that component should be billed separately using code L8048. This code should not be used for implanted prosthesis-anchoring components.

  3. Covered modifications or repairs are billed using code L8048 for any materials used and code L8049 for the labor components.

Code V2623 describes an ocular prosthesis, which is custom fabricated.

Code V2629 is used for an ocular prosthesis that is not custom fabricated
(i.e., stock prosthesis).

When a new ocular prosthesis component is provided as an integral part of an
orbital, upper facial or hemi-facial prosthesis, it should be billed using
code V2623 or V2629 on a separate claim line. When a replacement facial
prosthesis utilizes an ocular component from the prior prosthesis, the ocular
prosthesis code should not be billed.

When a prosthesis is needed for adjacent facial regions, a single code must be
used to bill for the item whenever possible. For example, if a defect involves
the nose and orbit, this should be billed using the hemi-facial prosthesis
code and not separate codes for the orbit and nose. This would apply even if
the prosthesis is fabricated in two separate parts.

When codes A4450, A4452 and A5120 are used with a facial prosthesis, they must
be billed with the AV modifier. For this policy, codes A4450, A4452 and A5120
are the only codes for which the AV modifier may be used.

Covered modifications or repairs are billed using code L8049 for the labor
components and code L8048 for any materials used. Time reported using code
L8049 should only be for laboratory modification/repair time and associated
prosthetic evaluation used only for services after 90 days from the date of
delivery of the prosthesis. Evaluation not associated with repair or
modification is noncovered and should not be coded as L8049.

Adhesives, adhesive remover, and tape used in conjunction with a facial
prosthesis should be billed using codes A4364, A4455, A4456, A4450, or A4452.
The unit of service is specified for each code. For tape, one unit of service
is 18 square inches. Therefore, a roll of tape 1/2" X 3 yds. would be 3 units;
1" x 3 yds. would be 6 units. Other skin care products related to the
prosthesis should generally not be billed; but, if they are billed at the
beneficiary's request, code A9270 (noncovered item or service) should be used.

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC)
Contractor for guidance on the correct coding of these items.