OAR 410-122-0680
Facial Prostheses
(1)
Indications and Coverage:(a)
Covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect;(b)
Adhesives, adhesive remover and tape used in conjunction with a facial prosthesis are covered. Other skin care products related to the prosthesis, including but not limited to cosmetics, skin cream, cleansers, etc., are not covered;(c)
The following services and items are included in the allowance for a facial prosthesis:(A)
Evaluation of the client;(B)
Pre-operative planning;(C)
Cost of materials;(D)
Labor involved in the fabrication and fitting of the prosthesis;(E)
Modifications to the prosthesis made at the time of delivery of the prosthesis or within 90 days thereafter;(F)
Repair due to normal wear or tear within 90 days of delivery;(G)
Follow-up visits within 90 days of delivery of the prosthesis;(d)
Modifications to a prosthesis that occur more than 90 days after delivery of the prosthesis and that are required because of a change in the client’s condition are covered;(e)
Repairs are covered when there has been accidental damage or extensive wear to the prosthesis that can be repaired. If the expense for repairs exceeds the estimated expense for a replacement prosthesis, no payments can be made for the amount of the excess;(f)
Follow-up visits which occur more than 90 days after delivery and which do not involve modification or repair of the prosthesis are non-covered services;(g)
Replacement of a facial prosthesis is covered in cases of loss or irreparable damage or wear or when required because of a change in the client’s condition that cannot be accommodated by modification of the existing prosthesis;(h)
When a prosthesis is needed for adjacent facial regions, a single code must be used to bill for the item, whenever possible. For example, if a defect involves the nose and orbit, this should be billed using the hemi-facial prosthesis code and not separate codes for the orbit and nose. This would apply even if the prosthesis is fabricated in two separate parts.(2)
Documentation: The following must be submitted for prior authorization (PA):(a)
An order for the initial prosthesis and/or related supplies which is signed and dated by the ordering prescribing practitioner must be kept on file by the prosthetist/supplier and submitted with request for PA;(b)
A separate prescribing practitioner order is not required for subsequent modifications, repairs or replacement of a facial prosthesis;(c)
A new prescribing practitioner order is required when different supplies are ordered;(d)
A photograph of the prosthesis and a photograph of the client without the prosthesis must be retained in the supplier’s record and must be submitted with the PA request;(e)
When code L8048 is used for a miscellaneous prosthesis or prosthetic component, the authorization request must be accompanied by a clear description and a drawing/copy of photograph of the item provided and the medical appropriateness;(f)
Requests for replacement, repair or modification of a facial prosthesis must include an explanation of the reason for the service;(g)
When replacement involves a new impression/moulage rather than use of a previous master model, the reason for the new impression/moulage must be clearly documented in the authorization request.(3)
Procedure Codes — Table 122-0680.
Source:
Rule 410-122-0680 — Facial Prostheses, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-122-0680.