CMS Billing & Documentation Review

One of the primary purposes of the American Association of Breast Care Professionals (AABCP) is to raise awareness of and interpret healthcare policies that affect mastectomy providers and clients.

In the fourth quarter of 2025, the Centers for Medicare and Medicaid Services (CMS) released a Documentation and Coverage Review for Breast Prostheses, clarifying and reviewing the current billing and coding for L8031 and L8035. It also listed improper payment data for 2024 and projected future payment concerns.

It should also be noted that changes to the External Breast Prosthesis LCD, the Article, and the Standard Documentation Requirements Article were released in October, 2025.

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Breast Prosthesis Codes

The L8031 is a staple billing code for post mastectomy items. It is defined as an external breast prosthesis with an integrated attachment.

The L8035 is a custom-fabricated breast prosthesis that allows for complete customization of an external prosthesis.

Medicare Improper Payment Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, breast prostheses carry an improper payment rate of 25%, representing an estimated $6.7 million in projected improper payments. This elevated rate underscores the importance of strict adherence to Medicare policy and documentation standards for mastectomy fitters and DMEPOS suppliers.

“breast prostheses carry an improper payment rate of 25%

2024 Medicare Fee-for-Service Supplemental Improper Payment Data

Key policy guidance is outlined in Article A52478, External Brest Prostheses Local Coverage Determination (LCD) L33317, and Article A55426, which details standard documentation requirements for all claims submitted to DMEPOS Medicare Administrative Contractors (MACs).

Primary Reasons for Claim Denials

Insufficient documentation is the leading cause of improper payments. This ccounting for 50% of denied or recouped claims during the 2024 reporting period.

Additional denial factors include lack of medical necessity (14.4%) and other errors (35.6%), such as duplicate billing, non-covered or unallowable services, or patient Medicare ineligibility.

For mastectomy fitters, these findings reinforce that accurate product selection alone is insufficient; comprehensive and explicit medical documentation is equally critical.

CMS Article

Nationally Covered Indications

Medicare covers breast prostheses for patients who have undergone a mastectomy, provided medical necessity is supported by appropriate ICD-10-CM diagnosis codes, as detailed in Article A52478.

Covered items include an external breast prosthesis garment with mastectomy form (HCPCS L-8015), typically used during the post-operative period or as an alternative to a mastectomy bra and prosthesis. Medicare also covers a mastectomy bra (HCPCS L-8000) when used with a covered mastectomy form (HCPCS L-8020) or silicone or equivalent breast prosthesis (HCPCS L-8030), provided the bra is designed to hold the form or prosthesis.

Reasonable Useful Lifetime Considerations

Medicare allows one breast prosthesis per side for the useful lifetime of the prosthesis, or two total breast prostheses for patients with bilateral mastectomies.

Replacements are permitted if a prosthesis is lost or irreparably damaged, or if a patient’s medical condition changes and necessitates a different type.

Nationally Non-Covered Indications

Certain breast prostheses are nationally non-covered due to a lack of demonstrated clinical benefit. These include silicone or equivalent prostheses with integral adhesive (HCPCS L-8031), which have not shown a clinical advantage over non-adhesive versions, and custom-fabricated breast prostheses (HCPCS L-8035), where medical necessity has not been established compared to prefabricated silicone prostheses.

Claims submitted for these items are denied as not reasonable and necessary.

Where Medicare goes, private insurance is soon to follow.

provider sentiment

Documentation Requirements and Common Pitfalls

To justify payment, DMEPOS claims must meet Medicare’s specific ordering and documentation requirements. A frequent error occurs when clinical records do not explicitly support the billed HCPCS code.

EXAMPLE:

“Claims for a mastectomy bra with an integrated breast prosthesis form (HCPCS L-8001) are often denied when the treating practitioner’s medical record fails to document the patient’s need for an integrated prosthesis, whether unilateral or bilateral. Even when a valid written order and proof of delivery are present, missing clinical justification results in claim denial and payment recoupment.“

Best Practices to Prevent Denials

To reduce improper payments and avoid claim denials, certifying physicians and mastectomy fitters must ensure the medical record clearly documents the

• Patient’s mastectomy status and relevant dates
• Specific type of breast prosthesis required
• Unilateral or bilateral need
• Medical rationale for any integrated or specialized features

Clear, complete, and consistent documentation remains the most effective strategy for compliance, reimbursement integrity, and high-quality patient care.

Final Thoughts

In light of the quiet changes made for breast prosthesis policies during 2025, AABCP is renewing its commitment to billing and regulatory education and interpretation. Additionally, for those providers who do not accept Medicare or Medicaid, a final thought. It has long been accepted that “when Medicare goes, private insurance is soon to follow.” In light of this adage, minor changes in private and Medicare Advantage policies are likely to follow.

The 2026 AABCP Regulatory Boot Camp addresses these and other billing rules and regulations.