Check out these FAQ for easy answers to common questions about Mastectomy Care Fitter Services.
Table of Contents
There is a surprising amount of information regarding mastectomy care provided by certified mastectomy fitters.
- Not all of it is accurate.
- Some information is outdated.
- Some information is country-specific.
- Some information is insurance or payor specific.
The American Association of Breast Care Professionals, in partnership with the Global Breast Care Network, endeavors to gather the most pressing questions regarding mastectomy surgery, post-surgical care, government and private insurance coverage, and the items and services provided by certified mastectomy fitters.
General Definitions & FAQ
What is Post-Mastectomy Care
Post Mastectomy services are healthcare items and professional services required after a mastectomy due to breast cancer or trauma, prophylactic mastectomy, or genetically induced developmental conditions of the breast.
Post-mastectomy is always considered healthcare – because these items treat conditions that have resulted from diseases and treatment of diseases of the breast.
What services are included in Post-Mastectomy Care?
Always measured face-to-face by a Certified Fitter, Mastectomy Care Treatment consists of the provision of a wide variety of services, including measurement and fit of:
- Post-surgical garments and bras, permanent bras
- External breast prostheses, post-op prostheses
- Permanent (silicone) prostheses and Nipple prostheses
- Custom breast prostheses
- Pocketed garments (bras, swimsuits, clothing)
- Lymphedema and post-surgical compression garments
What items are included in Post-Mastectomy Care
Mastectomy Care Treatment consists of the provision of a wide variety of services, including measurement and fit of:
- Post-surgical garments and bras, permanent bras
- External breast prostheses, soft un-weighted post-op prostheses
- Weighted prostheses
- Permanent (silicone) prostheses and Nipple prostheses
- Custom breast prostheses
- Pocketed garments (bras, swimsuits, clothing)
- Lymphedema and post-surgical compression garments
- Wigs & headwear
Does Private Insurance cover mastectomy items?
Most private insurance plans cover mastectomy items either in a limited fashion or as a result of the Women’s Health and Cancer Rights Act (WHCRA). However, since breast prostheses are DMEPOS items, they may be subject to a separate deductible
Does Medicare cover mastectomy items?
This is often a misqoted FAQ. Medicare covers mastectomy items and services for a covered mastectomy, including breast cancer and prophylactic surgeries.
Do Medicare Advantage policies cover mastectomy items?
Medicare Advantage policies must follow coverage guidelines, at the minimum, of Traditional Medicare. In this manner, most Medicare Advantage plans cover mastectomy items and services.
Does state Medicaid cover mastectomy items?
This FAQ is complex with no easy answer. Many, but not all, state Medicaids cover mastectomy items. However, most state Medicaid policies limit the frequency and number of services.
Insurance and Coverage for Mastectomy Care
How many bras are allowed per year?
The number of pocketed mastectomy bras (L8000) that can be billed at a given time depends on the insurance carrier and type of coverage. However, Medicare allows for as many mastectomy bras as are medically necessary or the number determined byt the patient and her doctor as needed.
What Medicare supplier documents dictate mastectomy reimbursement policy?
There are more than two dozen documents that directly effect reimbursement policy for post-mastectdomy items, a part of DMEPOS, at the Center for Medicare and Medicaid Services (CMS). However the following are the three most quote and the documentation that private and commercial insurers rely on the most.
- The Documentation for DMEPOS Article.
- The External Breast Prosthesis Local Coverage Determination (LCD)
- The External Breast Prosthesis Policy Article
Coding Mastectomy Items
L8000: What mastectomy product does the code L8000 describe?
L8000 describes a pocketed bra where the pocket is used to hold an external breast prosthesis. It can either be pre-manufactured with a pocket or shelf or a sewn-in pocket may be untilized.
L8001: What mastectomy product does the code L8001 describe?
L8001 describes a pocketed mastectomy bra with an integrated breast prosthesis on one side (RT or LT).
L8002: What mastectomy product does the code L8002 describe?
L8002 describes a pocketed mastectomy bra with integrated breast prostheses on both sides (RT and LT). What mastectomy product does the code L8015 describe?
L8015: What mastectomy product does the code L8015 describe?
L8015 describes a post-surgical garment for use after a mastectomy with a post-surgical mastectomy form, usually referred to as an unweighted ‘puff’ and not to be confused with the L8020 mastefctomy form or L8030 breast prosthesis. The L8015 garment is to be used in the period after surgery for healing; before a permanent prosthesis is provided or as a replacement for L8000. It is also referred to as a post-surgical camisole or compression garment.
L8020: What mastectomy product does the code L8020 describe?
L8020 describes a non-silicone breast prosthesis. Typical prostheses that meet the description of an L8020 include full size foam, soft, unweighted, and soft weighted forms of all shapes.
L8030: What mastectomy product does the code L8030 describe?
L8030 describes a silicone breast prosthesis, any shape, any weight, to be used with a pocketed garment, no integral adhesive.
What mastectomy product does the code L8031 describe?
L8031 describes a silicone breast prosthesis with an integral adhesive.
L8032: What mastectomy product does the code L8032 describe?
L8032 describes a prefabricated, reusable Nipple Prosthesis made from any material.
L8033: What mastectomy product does the code L8033 describe?
L8033 describes a custom-fabricated, reusable Nipple Prosthesis made from any material.
L8035: What mastectomy product does the code L8035 describe?
L8035 describes a Custom Breast Prosthesis molded to an individual patient, made from any material.
L8039: What mastectomy product does the code L8039 describe?
L8039 describes a breast prosthesis (not otherwise specified) that does not have a designated code. It is often referred to as a “miscellaneous” code.
A4280: What mastectomy product does the code A4280 describe?
A4280 describles an adhesive skin support attachment, any type for use with an external breast prostheses. This could be a roll-on adhesive, adhesive strips, adhesive tape, or integral adhesive.