OAR 410-122-0655
External Breast Prostheses

(1)

Indications and Limitations of Coverage and Medical Appropriateness:

(a)

The Division may cover an external breast prosthesis for a client who has had a mastectomy;

(b)

An external breast prosthesis garment, with mastectomy form (L8015) may be covered for use in the postoperative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis;

(c)

An external breast prosthesis of a different type may be covered if there is a change in the client’s medical condition necessitating a different type of item;

(d)

The Division will pay for only one breast prosthesis per side for the useful lifetime of the prosthesis;

(e)

The Division will pay for a breast prosthesis for a client residing in a nursing facility;

(f)

Two prostheses, one per side, are allowed for a client who has had bilateral mastectomies;

(g)

More than one external breast prosthesis per side is not covered;

(h)

An external breast prosthesis of the same type may be replaced if it is lost or is irreparably damaged (this does not include ordinary wear and tear);

(i)

Replacement sooner than the useful lifetime because of ordinary wear and tear is not covered.

(2)

Guidelines:

(a)

Use code A4280 when billing for an adhesive skin support that attaches an external breast prosthesis directly to the chest wall;

(b)

L8000 is limited to a maximum of four units every 12 months;

(c)

Code L8015 describes a camisole type undergarment with polyester fill used post mastectomy;

(d)

The right (RT) and left (LT) modifiers must be used with these codes. When the same code for two breast prostheses are billed for both breasts on the same date, the items (RT and LT) must be entered on the same line of the claim form using the RTLT modifier and two units of service;

(e)

The useful lifetime expectancy for silicone breast prostheses is two years;

(f)

For fabric, foam, or fiber filled breast prostheses, the useful lifetime expectancy is six months.

(3)

Requirements:

(a)

For services that do not require prior authorization (PA), the durable medical equipment, prosthetic, orthotic and supplies (DMEPOS) provider must have documentation on file which supports conditions of coverage as specified in this rule are met;

(b)

For services that require PA, the DMEPOS provider must submit documentation for review which supports conditions of coverage as specified in this rule are met;

(c)

Medical records must be made available to the Division on request.

(4)

Table 122-0655 (Procedure Codes): The procedure codes in this table may be covered for purchase.
[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

Source: Rule 410-122-0655 — External Breast Prostheses, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-122-0655.

410‑122‑0010
Definitions 410‑122‑0020
Orders 410‑122‑0040
Prior Authorization 410‑122‑0080
Conditions of Coverage, Limitations, and Restrictions 410‑122‑0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients) 410‑122‑0180
Healthcare Common Procedure Coding System Level II Coding 410‑122‑0182
Legend 410‑122‑0184
Repairs, Servicing, Replacement, Delivery, and Dispensing 410‑122‑0186
Payment Methodology 410‑122‑0188
DMEPOS Rebate Agreements 410‑122‑0200
Pulse Oximeter for Home Use 410‑122‑0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea 410‑122‑0203
Oxygen and Oxygen Equipment 410‑122‑0204
Nebulizer 410‑122‑0205
Respiratory Assist Devices 410‑122‑0206
Intermittent Positive Pressure Breathing 410‑122‑0207
Respiratory Supplies 410‑122‑0208
Suction Pumps 410‑122‑0209
Tracheostomy Care Supplies 410‑122‑0210
Ventilators 410‑122‑0211
Cough Stimulating Device 410‑122‑0220
Pacemaker Monitor 410‑122‑0240
Apnea Monitors for Infants 410‑122‑0250
Breast Pumps 410‑122‑0260
Home Uterine Monitoring 410‑122‑0280
Heating/Cooling Accessories 410‑122‑0300
Light Therapy 410‑122‑0320
Manual Wheelchair Base 410‑122‑0325
Power Wheelchair Base 410‑122‑0330
Power-Operated Vehicle 410‑122‑0340
Wheelchair Options/Accessories 410‑122‑0360
Canes and Crutches 410‑122‑0365
Standing and Positioning Aids 410‑122‑0375
Walkers 410‑122‑0380
Hospital Beds 410‑122‑0400
Pressure Reducing Support Surfaces 410‑122‑0420
Hospital Bed Accessories 410‑122‑0475
Therapeutic Shoes for Diabetics 410‑122‑0510
Osteogenesis Stimulator 410‑122‑0515
Neuromuscular Electrical Stimulator (NMES) 410‑122‑0520
Glucose Monitors and Diabetic Supplies 410‑122‑0525
External Insulin Infusion Pump 410‑122‑0540
Ostomy Supplies 410‑122‑0560
Urological Supplies 410‑122‑0580
Bath Supplies 410‑122‑0590
Patient Lifts 410‑122‑0600
Toilet Supplies 410‑122‑0620
Miscellaneous Supplies 410‑122‑0625
Surgical Dressing 410‑122‑0630
Incontinent Supplies 410‑122‑0640
Eye Prostheses 410‑122‑0655
External Breast Prostheses 410‑122‑0658
Gradient Compression Stockings/Sleeves 410‑122‑0660
Orthotics and Prosthetics 410‑122‑0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses 410‑122‑0678
Dynamic Adjustable Extension/Flexion Device 410‑122‑0680
Facial Prostheses 410‑122‑0700
Negative Pressure Wound Therapy Pumps 410‑122‑0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0655’s source at or​.us