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    v1.0.31
    OpenPayerPolicy UpdatesProsthetics & OrthoticsAetna External Breast Prosthesis Coverage | OpenPa…
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    CurrentAetnaPolicy 0097

    External Breast Prosthesis

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    Defines Aetna's coverage and medical necessity criteria for external breast prostheses, mastectomy bras, prosthetic garments, lymphedema sleeves, and replacement intervals for members after mastectomy or for persons with gender dysphoria.

    Policy Summary
    PayerAetna
    PolicyExternal Breast Prosthesis
    Policy CodePolicy 0097
    Change TypeNo material change
    Effective DateJan 12, 1996
    Last ReviewDec 15, 2023
    Next Review DateJan 25, 2024
    Key ActionDocument medical necessity for mastectomy or lumpectomy, or diagnosis of gender dysphoria; document need for more frequent replacements if requested.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Up to 6mastectomy bras (initial/replacements per 12 mo)
    24 mosilicone prosthesis replacement interval
    6 mofabric/foam prosthesis replacement
    3 monipple prosthesis replacement
    3 / 2lymphedema sleeves (initial / replacements)

    Coverage and Medical Necessity Criteria

    Medical necessity and quantity/timeframe criteria

    Covered when ANY of the following indications are met and plan-specific limits are observed:

    Indications: 1) Following a medically necessary mastectomy or lumpectomy; OR 2) For persons with gender dysphoria.

    [[chunk 4]]

    Mastectomy bras: Up to six breast prosthesis bras (mastectomy bras) initially following a medically necessary mastectomy; or for members who have a medically necessary mastectomy form or silicone (or equal) breast prosthesis when the pocket of the bra is used to hold the form/prosthesis; or for members with gender dysphoria.Up to 6 initially; check plan-specific limits (some plans limit to initial prosthesis and fewer bras)

    [[chunk 4]]

    Mastectomy bra replacements: Up to six breast prosthesis bra (mastectomy bra) replacements every 12 months.Up to 6 replacements every 12 months

    [[chunk 4]]

    External breast prosthesis garment with mastectomy form is covered for use in the post-operative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis; also covered for members with gender dysphoria.

    [[chunk 4]]

    Number per side: Only one breast prosthesis per side for the useful lifetime of the prosthesis; two prostheses (one per side) are allowed for members who have had bilateral mastectomies or for members with gender dysphoria.One per side; bilateral allowed when indicated

    [[chunk 4]]

    Replacement intervals: One replacement silicone breast prosthesis every 24 months. For fabric, foam, or fiber-filled breast prostheses, replacements are medically necessary every 6 months. Replacements of nipple prostheses are medically necessary every 3 months. The medical necessity of more frequent replacements must be documented.24 months (silicone); 6 months (fabric/foam/fiber); 3 months (nipple)

    [[chunk 4]][[chunk 5]]

    Lymphedema sleeves: Three gradient compression lymphedema sleeves initially per affected arm, then two replacements every six months.Initial 3 per affected arm; then 2 replacements every 6 months

    [[chunk 5]]

    Not medically necessary items: A breast prosthesis (silicone or equal) with integrated adhesive (L8031) is considered not medically necessary. Additional features of custom‑fabricated breast prostheses compared to prefabricated silicone prostheses are not medically necessary. More than one external breast prosthesis per side is not medically necessary.

    [[chunk 5]]

    A breast prosthesis with integrated adhesive (HCPCS code L8031) is considered not medically necessary. The policy states these integrated-adhesive prostheses have not been demonstrated to provide a clinical advantage over prostheses without integrated adhesive.

    The policy specifies that the additional features of a custom-fabricated breast prosthesis, when compared to a pre-fabricated silicone prosthesis, are not medically necessary. In other words, enhancements beyond what a prefabricated silicone prosthesis provides are not supported as medically necessary.

    Coverage for more than one external breast prosthesis per side is deemed not medically necessary. The policy limits benefit to one prosthesis for the useful lifetime of the prosthesis per side.

    Specifically, a silicone breast prosthesis with integrated adhesive (HCPCS L8031) is listed as not medically necessary because it has not been shown to have a clinical advantage over prostheses without integrated adhesive.

    The policy clarifies that custom-fabricated prostheses do not become medically necessary solely due to additional features relative to prefabricated silicone prostheses; such additional features are considered not medically necessary.

    The policy reiterates that coverage for more than one external breast prosthesis beyond one per side is not medically necessary, reinforcing the single-prosthesis-per-side limitation.

    HCPCS, CPT, and ICD-10 Coding

    Covered HCPCS Codes (if selection criteria are met)HCPCSCovered
    A4280Adhesive skin support attachment for use with external breast prosthesis, each.
    A6549Gradient compression stocking/sleeve, not otherwise specified.
    L8000Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type.
    L8001Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type.
    L8002Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type.
    L8010Breast prosthesis, mastectomy sleeve.
    L8015External breast prosthesis garment, with mastectomy form, post mastectomy.
    L8020Breast prosthesis, mastectomy form.
    L8030Breast prosthesis, silicone or equal.
    L8032Nipple prosthesis, prefabricated, reusable, any type, each.
    1–10 of 15
    1/2
    HCPCS codes not covered for indications listed in the CPBHCPCSNot Covered
    L8031Breast prosthesis, silicone or equal, with integral adhesive.
    L8035Custom breast prosthesis, post mastectomy, molded to patient model.
    Related CPT codesCPT
    19300-19307Mastectomy procedures (related CPT codes referenced).
    ICD-10 Codes covered if selection criteria are metICD-10Covered
    C50.011 - C50.919Malignant neoplasm of breast (ICD-10 range).
    C79.81Secondary malignant neoplasm of breast.
    D05.01 - D05.99Carcinoma in situ of breast.
    F64.0 - F64.9Gender identity disorders [gender dysphoria].
    N60.11 - N60.19Diffuse cystic mastopathy [severe fibrocystic disease].
    Z85.3Personal history of malignant neoplasm of breast.
    Z90.10 - Z90.13Acquired absence of breast and nipple.

    Provider Authorization, Documentation, and Billing Guidance

    Prior Authorization

    Obtain prior authorization and verify plan-specific limits

    Prior authorization may be required per plan for covered HCPCS codes listed in this policy (for example: L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8032, L8033, L8039, S8422, S8423, S8424, A4280, A6549). Check the member's benefit plan description for plan-specific limits on initial versus replacement prostheses before ordering or billing.

    • Verify whether the member’s plan requires prior authorization for the specific HCPCS code being requested.
    • Confirm plan limits that may restrict coverage to an initial prosthesis only or limit the number of replacement bras/prostheses.
    Note

    Confirm indication and use policy HCPCS codes

    For any request, confirm coverage criteria are met (mastectomy/lumpectomy or gender dysphoria) and follow documentation, authorization, and coding guidance in this policy prior to provision.

    • Confirm indication meets policy: following a medically necessary mastectomy or lumpectomy, or for persons with gender dysphoria.

    Background

    External breast prostheses and mastectomy bras serve as cosmetic and functional replacements following mastectomy or lumpectomy and are also covered for persons with gender dysphoria. Mastectomy bras provide pockets to hold a prosthesis or mastectomy form adjacent to the chest wall, and external prosthetic garments can be used postoperatively prior to a permanent prosthesis or as an alternative to a mastectomy bra and prosthesis.

    Definitions

    Custom molded prosthesis — definition
    TermCustom breast prosthesis, post mastectomy, molded to patient model
    DefinitionA molded-to-patient-model custom breast prosthesis made by taking an impression of the chest wall and creating a positive model on which the prosthesis is molded.
    FabricationIndividually made for a specific patient starting with basic materials; impression of chest wall used to form positive model.
    ClassificationA specific type of custom-fabricated prosthesis (custom fabricated → molded to patient model).
    Mastectomy bra (without integrated form) — definition
    TermBreast prosthesis, mastectomy bra, without integrated breast prosthesis form
    Policy Summary
    PayerAetna
    PolicyExternal Breast Prosthesis
    Policy CodePolicy 0097
    Change TypeNo material change
    Effective DateJan 12, 1996
    Last ReviewDec 15, 2023
    Next Review DateJan 25, 2024
    Key ActionDocument medical necessity for mastectomy or lumpectomy, or diagnosis of gender dysphoria; document need for more frequent replacements if requested.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaHCPCS, CPT, and ICD-10 CodingProvider Authorization, Documentation, and Billing GuidanceBackgroundDefinitions
  1. Use the HCPCS codes listed in the policy that correspond to the item being provided and check whether prior authorization is required.
    2. Documentation Required

    Document medical necessity and any need for more frequent replacements

    Document the medical necessity of the prosthesis by recording the qualifying indication (medically necessary mastectomy or lumpectomy, or diagnosis of gender dysphoria) and, if requesting replacements more frequently than standard intervals, provide supporting justification in the medical record.

    • Record the surgical history (date and type of mastectomy or lumpectomy) or diagnosis code for gender dysphoria.
    • If requesting replacements sooner than policy intervals (e.g., more frequent than 24 months for silicone, 6 months for fabric/foam/fiber, or 3 months for nipple prostheses), include clinical evidence documenting the need for more frequent replacement.
    Denial Risk

    Verify plan benefit limits — replacements may be denied

    Be aware that some Aetna plans limit coverage to an initial prosthesis and do not cover replacement prostheses; under those plans replacements may be denied. Always check the member’s benefit plan description for these limitations before ordering replacements.

    • Under plans that limit coverage to an initial prosthesis, an initial external breast prosthesis and up to four initial mastectomy bras may be covered (initial defined as within one year after mastectomy).
    • If a plan excludes replacement prostheses, submit documentation of medical necessity and prior authorization but anticipate potential denial based on the member’s benefit limits.
    DefinitionA bra with pockets intended to hold a mastectomy form or breast prosthesis held adjacent to the chest wall; does not include an integrated breast prosthesis.
    Materials and featuresMay be constructed of any material (e.g., cotton, polyester), any closure type or location, any size, with or without integrated structural support (e.g., underwire).
    PurposeHolds a separate mastectomy form or external breast prosthesis within pocket(s) for cosmetic/functional replacement post mastectomy or lumpectomy.
    Postoperative prosthetic garment — definition
    TermExternal breast prosthesis garment, with mastectomy form, post mastectomy
    DefinitionA camisole-type undergarment with polyester fill used in the post‑mastectomy period; includes a mastectomy form within the garment.
    Use caseUsed post mastectomy prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis.
    ConstructionCamisole-style garment containing polyester fill to provide a mastectomy form or contouring after surgery.