The Centers for Medicare and Medicaid Services updated the External Breast Prosthesis LCD in 2024 and 2025. Learn how documentation, refill timing, and HCPCS coding revisions affect mastectomy fitters and patient access.
The Local Coverage Determinations (LCD) is considered to be the Ground Truth Final Answer (GTFA) for Medicare coverage for External Breast Prostheses, including silicone breast prosthesis, mastectomy bras, partial shapers, and other items.
But did you know that between 2024 and 2025, CMS implemented two important updates: a documentation-focused revision and a coding cleanup. These adjustments did not change beneficiary eligibility, but they do affect how DMEPOS suppliers manage refills and bill Medicare accurately.
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2024 Revision (R9): Updated Refill and Documentation Requirements
AABCP understands that this change was more than a year ago, but it bears revisiting.
Effective January 1, 2024, CMS added updated DMEPOS requirements designed to strengthen compliance and reduce improper payments. The revision clarifies how suppliers must verify medical necessity before dispensing refills.
Key 2024 Changes
Affirmative Confirmation Required
Suppliers must obtain and document an affirmative response from the beneficiary or caregiver before providing any refill. Automated refill assumptions are no longer acceptable.
Updated Refill Timing Language
The terminology “approaching exhaustion” was replaced with “expected to end,” creating a clearer standard for when a supplier should initiate contact.
Contact Window Extended to 30 Days
Suppliers may now contact beneficiaries no earlier than 30 days before the current supply is expected to end. This is an increase from the previous 14-day window.
Delivery Timing Restricted
Suppliers may deliver a refill no more than 10 days before the expected end of the beneficiary’s current supply. This ensures refills align with actual need.
Why the 2024 Update Matters
These refinements strengthen documentation integrity without altering coverage criteria. Suppliers must follow stricter administrative procedures to help protect Medicare from early or unnecessary refills while ensuring beneficiaries receive supplies when needed.
2025 Revision (R10): Removal of Discontinued HCPCS Code
Effective April 1, 2025, CMS updated the LCD to reflect national HCPCS code changes. This was done to more closely align with policy and to recognize that the lymphedema compression sleeve (L8010) is now incorporated within the Lymphdema LCD as a benefit category defined in section 1861(s)(2)(JJ) of the Social Security Act (the Act), and further defined in Medicare regulations at 42 Code of Federal Regulations (CFR) 410.36(a)(4).
What Was Updated?
- Removal of HCPCS Code L8010
The code was eliminated from the LCD because it was discontinued under CMS’s national coding determinations. This ensures suppliers cannot bill Medicare using an obsolete code.
What This Means for Suppliers
This update does not affect clinical coverage or patient eligibility. It simply keeps the LCD aligned with current HCPCS billing standards and helps prevent claim denials related to outdated coding.
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