Summary & Overview
HCPCS L8035: Custom Breast Prosthesis, Post Mastectomy
HCPCS Level II code L8035 represents a custom breast prosthesis molded to a patient model for use after mastectomy. This code captures a personalized external prosthetic device intended to restore breast contour and symmetry following surgical breast removal. Nationally, accurate coding for custom prostheses affects coverage determinations, patient access to appropriate prosthetic options, and claims processing for durable medical equipment and prosthetics providers.
Key payers referenced include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the clinical context for post-mastectomy external prostheses, typical sites of service where the device is provided, and what to expect in payer coverage patterns. The publication outlines common benchmarks and policy considerations that influence coverage decisions and billing for custom prostheses, including documentation elements that payers commonly review.
This summary provides clinicians, billing professionals, and administrative staff with concise information about the clinical purpose of L8035, the service setting, and which major payers are typically involved in coverage. Data not available in the input for associated taxonomies, ICD-10 diagnoses, or specific related codes is noted where applicable.
Billing Code Overview
HCPCS Level II code L8035 describes a custom breast prosthesis, post mastectomy, molded to patient model. This item is a custom-fabricated external prosthetic device created from a patient-specific mold to restore breast contour following mastectomy.
Service Type: Prosthetic device fabrication and provision
Typical Site of Service: Outpatient prosthetics/orthotics clinic, durable medical equipment supplier, or outpatient surgical/prosthetic fitting center
Data not available in the input for associated taxonomies, ICD-10 diagnoses, or related codes.
Clinical & Coding Specifications
Clinical Context
A 52-year-old female status post unilateral mastectomy for invasive ductal carcinoma presents for fitting and delivery of a custom molded breast prosthesis. The patient completed adjuvant therapy and has stable surgical sites with healed incisions and no active infection. An anaplastologist or certified prosthetist conducts a consultation, obtains a cast or digital model of the chest wall, selects appropriate shape, skin tone, and nipple-areola options, and fabricates a custom silicone prosthesis tailored to the patient’s chest contour. Final fitting occurs in an outpatient prosthetics clinic or specialized breast center where adjustments to weight, symmetry, and strap/garment compatibility are performed. Typical workflow: initial consult and measurement, model capture (molding or scanning), custom fabrication in a certified lab, professional fitting and patient education on use and care, and documentation of medical necessity and product details for billing. Typical site of service is an outpatient prosthetics clinic, breast center, or durable medical equipment supplier with on-site fitting capabilities.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
LT | Left side | When the prosthesis is for the left breast after left mastectomy |
RT |