Answers to common questions about Mastectomy Care Fitter Services. 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- Some information is outdated.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 payer specific.
The American Association of Breast Care Professionals, in partnership with the International Society of Breast Care Professionals, 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 – Mastectomy Care
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 and by a Certified Fitter.
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, post-op prostheses.
- Permanent (silicone) prostheses and Nipple prostheses.
- Custom breast prostheses.
- Pocketed garments (bras, swimsuits, clothing).
- Lymphedema and post-surgical compression garments.
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?
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, at the minimum, Traditional Medicare. In this manner, most Medicare Advantage plans cover mastectomy items and services.
Does state Medicaid cover mastectomy items?
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?
As many as are medically necessary. The patient and her doctor determine the need.
What Medicare Documents dictate mastectomy reimbursement policy?
The External Breast Prosthesis Local Coverage Determination (LCD), The External Breast Prosthesis Policy Article, and the Documentation for DMEPOS Article.
Coding Mastectomy Items
Mastectomy Care Bras & Garments
How many mastectomy bras can be billed?
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.
What mastectomy product does the code L8000 describe?
L8000 describes a pocketed bra where the pocket is used to hold an external breast prosthesis.
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).
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 describes a post-surgical garment for use after a mastectomy with a post-surgical style prosthesis, usually referred to as an unweighted ‘puff.’ The garment is to be used in the period after surgery for healing; before a permanent prosthesis is provided. And L8015 is also referred to as a post-surgical camisole or compression garment.
Mastectomy Care Prostheses
What mastectomy product does the code L8020 describe?
L8020 describes a non-silicone breast prosthesis.
What mastectomy product does the code L8030 describe?
L8030 describes a silicone breast prosthesis with no integral adhesive.
What mastectomy product does the code L8031 describe?
L8031 describes a silicone breast prosthesis with an integral adhesive.
What mastectomy product does the code L8032 describe?
L8032 describes a prefabricated, reusable Nipple Prosthesis made from any material.
What mastectomy product does the code L8033 describe?
L8033 describes a custom-fabricated, reusable Nipple Prosthesis made from any material.
What mastectomy product does the code L8035 describe?
L8035 describes a Custom Breast Prosthesis molded to an individual patient, made from any material.
What mastectomy product does the code L8039 describe?
L8039 describes a billing code for all items and services that do not have a designated code.