CurrentAetnaPolicy 0620

Facial Prostheses, External

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Coverage and medical necessity criteria for removable superficial facial prostheses and associated supplies for members with loss or absence of facial tissue due to disease, trauma, surgery, or congenital defect. Applies to providers submitting claims to Aetna for these devices and related supplies.

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CurrentAetnaPolicy 0620

Facial Prostheses, External

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Policy Summary

PayerAetna

PolicyFacial Prostheses, External

Policy CodePolicy 0620

Change TypeNo material change

Effective DateJun 18, 2002

Last ReviewSep 12, 2023

Next Review DateJul 11, 2024

Key ActionObtain prior authorization when required and document medical necessity and fabrication, fitting, and modifications within the allowance period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CoveredSuperficial facial prosthesis

CoveredAdhesives & removers

Not coveredCosmetics / skin care

IncludesAllowance includes

MultipleCertain HCPCS/CPT

Coverage and Medical Necessity Criteria

inv-01: Medical Necessity - Indications

Covered when ANY of the following primary conditions are present:

Indications: Presence of loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect

Coverage applies regardless of whether the prosthesis restores function

Other skin care products related to the prosthesis, including but not limited to cosmetics, skin cream, cleansers, and similar non-medical items are not covered. These items are not considered medical supplies and claims for HCPCS codes A6250 and A6260 are specifically listed as not covered for the indications in this policy.

The use of cosmetics and other non-medical skin care products in connection with facial prostheses is considered not medically necessary and is excluded from coverage. Documentation and claims for such products should not be submitted as medically necessary items under this policy.

Codes and Coding Guidance

Covered HCPCS Codes (if selection criteria met)HCPCSCovered

A4364	Adhesive, liquid, or equal, any type, per oz.
A4450	Tape, non-waterproof, per 18 sq. in.
A4452	Tape, waterproof, per 18 sq. in.
A4455	Adhesive remover or solvent (for tape, cement or other adhesive), per oz.
A4456	Adhesive remover, wipes, any type, each.
L8040	Nasal prosthesis, provided by a nonphysician.
L8041	Midfacial prosthesis, provided by a nonphysician.
L8042	Orbital prosthesis, provided by a nonphysician.
L8043	Upper facial prosthesis, provided by a nonphysician.
L8044	Hemi-facial prosthesis, provided by a nonphysician.

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Covered CPT Codes (if selection criteria met)CPTCovered

21076	Impression and custom preparation; surgical obturator prosthesis.
21077	Orbital prosthesis.
21079	Interim obturator prosthesis.
21080	Definitive obturator prosthesis.
21081	Mandibular resection prosthesis.
21082	Palatal augmentation prosthesis.
21083	Palatal lift prosthesis.
21085	Oral surgical splint.
21086	Auricular prosthesis.
21087	Nasal prosthesis.

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HCPCS Codes not covered for indications listed in the CPBHCPCSNot Covered

A6250	Skin sealants, protectants, moisturizers, ointments, any type, any size.
A6260	Wound cleansers, any type, any size.

ICD-10 Codes (covered if selection criteria met)ICD-10

Q11.1	Other anophthalmos [congenital absence of eye].
Q16.0	Congenital absence of (ear) auricle.
Q16.9	Congenital malformation of ear causing impairment of hearing, unspecified [absence of ear, congenital].
Q17.8	Other specified congenital malformations of ear.
Q18.8	Other specified congenital malformations of face and neck [loss of facial tissue].
Q30.1	Agenesis and underdevelopment of nose [absent nose].
Q67.0	Congenital deformities of skull, face, and jaw [absence of facial tissue].
Q67.4	Congenital deformities of skull, face, and jaw [absence of facial tissue].
Z90.01	Acquired absence of eye.

Provider Requirements and Billing Actions

Prior Authorization

Prior Authorization and Code Verification

Selected CPT and HCPCS codes for facial prostheses and related supplies require coverage criteria to be met. Prior authorization may be required per payer policy; verify benefit coverage and obtain authorization when indicated to avoid claim denials.

Affected codes include CPT 21076-21088 and HCPCS L8040-L8047, A4364, A4450, A4452, A4455, A4456

Denial Risk

Excluded Items — Denial Risk

Claims for skin care products related to prostheses (for example cosmetics, skin creams, cleansers) and HCPCS A6250/A6260 are not covered and may be denied. Confirm that billed items are medically necessary prosthesis supplies and not routine cosmetic or skincare products.

Non-covered examples: cosmetics, skin creams, cleansers

Background

External facial prostheses are removable superficial devices that restore part or all of facial structures (for example, nose, orbit, ear, midface, hemi-face, upper face) lost due to congenital absence, disease, trauma, or surgery. Types of prostheses include nasal, mid-facial, orbital, upper facial, hemi-facial, auricular, superficial partial facial, and nasal septal prostheses. Coverage is provided when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect, regardless of whether the prosthesis restores function; adhesives, adhesive remover, and tape used with the prosthesis are also covered.

Definitions of Prosthesis Types

External nasal prosthesis

DefinitionAn external nasal prosthesis is a removable superficial prosthesis that restores all or part of the nose; it may include the nasal septum.

Anatomic scopeRestores all or part of external nasal structures; may include internal nasal septal component when specified.

Use caseIndicated for loss or absence of nasal tissue due to congenital defect, disease, trauma, or surgery when coverage criteria are met.

External orbital prosthesis

DefinitionAn external orbital prosthesis is a removable superficial prosthesis that restores the eyelids and the hard and soft tissue of the orbit; it may include the eyebrow and may or may not include the ocular prosthesis component.

Anatomic scopeRestores eyelids and orbital hard/soft tissues; inclusion of ocular prosthesis component is optional.

Policy Summary

PayerAetna

PolicyFacial Prostheses, External

Policy CodePolicy 0620

Change TypeNo material change

Effective DateJun 18, 2002

Last ReviewSep 12, 2023

Next Review DateJul 11, 2024

Key ActionObtain prior authorization when required and document medical necessity and fabrication, fitting, and modifications within the allowance period.

SourceLink

On This Page

HCPCS A6250/A6260 — not covered

Documentation Required

Required Documentation

Documentation must demonstrate medical necessity and support the fabrication, fitting, and any modifications to the prosthesis. Include clinical rationale for tissue loss (disease, trauma, surgery, or congenital defect), description of prior conservative measures if applicable, dates of delivery, and details of the fabrication process. Use operative notes, clinical evaluations, and vendor invoices as appropriate.

Document diagnosis and reason for prosthesis (e.g., loss or absence of facial tissue)
Include vendor fabrication records, fitting notes, and delivery date
Note any changes in condition that justify later modifications

Billing Rule

Allowance and Included Services

The allowance for a facial prosthesis includes evaluation, pre-operative planning, materials, fabrication and fitting labor, modifications made at delivery or within 90 days, repairs for normal wear/tear within 90 days, and follow-up visits within 90 days. Modifications or repairs occurring more than 90 days after delivery are separately payable only if medically necessary due to a change in the member’s condition; submit supporting documentation when billing separately.

Included in allowance: evaluation, pre-op planning, materials, fabrication/fitting labor
Included in allowance: modifications, repairs, and follow-up within 90 days of delivery
Separately payable: modifications >90 days post-delivery if medically necessary with documentation

Use caseUsed when orbital tissues are absent or deficient from congenital conditions, disease, trauma, or surgery and medical necessity criteria are satisfied.

External mid-facial prosthesis

DefinitionAn external mid-facial prosthesis is a removable superficial prosthesis that restores part or all of the nose plus significant adjacent facial tissue/structures but does not include the orbit or intraoral maxillary component.

Anatomic scopeRestores the nose plus adjacent tissues such as cheek, upper lip, or forehead, but excludes the orbit and intraoral maxillary structures.

Use caseAppropriate when loss involves the nose and contiguous facial areas (cheek, upper lip, forehead) from congenital absence, disease, trauma, or surgery and coverage criteria are met.