Currentblue cross blue shield - michiganPolicy MAPPO 1008

City of Livonia MA Plan Mastectomy sleeves

Defines coverage, payment, billing, and provider requirements for mastectomy sleeves (HCPCS L8010) under the City of Livonia Medicare Plus Blue Group PPO plan and who is affected (members and DME/Prosthetics suppliers).

Policy Summary

Payerblue cross blue shield - michigan

PolicyCity of Livonia MA Plan Mastectomy sleeves

Policy CodePolicy MAPPO 1008

Change TypeAdded payment amount details

Effective DateJan 1, 2023

Next Review DateOct 15, 2024

Key ActionObtain maximum payment amounts from Northwood or the provider website before billing.

SourceLink

POLICY UPDATE CHANGES

Added DME/POS vendor maximum payment amount information.

L8010HCPCS code covered

2/12moFrequency limitation per member

No cost shareMember financial responsibility

NoneClinical restrictions

Coverage Criteria and Operational Rules

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Coverage criteria and operational rules

Conditions and operational rules for payment, reimbursement, and billing.

ALL of the following

Eligible provider: DME / Prosthetics and Orthotics supplier.
Payable location: No restrictions.
HCPCS code: L8010 (mastectomy sleeve).
Frequency: 2 units per 12 months, per individual.
Diagnosis restrictions: No restrictions.
Age restrictions: No restrictions.

Reimbursement and payment rules

Plan maximum payment amount applies: provider will be paid the lesser of the plan's maximum payment amount or the provider's charge.
Source of maximum payment amount: for Northwood providers contact Northwood, Inc.; for non-Northwood providers see the Medicare Plus Blue Enhanced Benefits Fee Schedule on the provider website.
Payment represents payment in full; providers may not balance bill the member for the difference between the allowed amount and the charge.

Member financial responsibility

No member cost sharing; mastectomy sleeves covered at 100%.
If a member elects to receive a noncovered service, the member is responsible for the entire charge for that service.
Providers may not have members sign an Advance Beneficiary Notice (ABN) to transfer financial responsibility for items/services that may be noncovered; if coverage is uncertain, obtain a coverage determination from Blue Cross before providing the item or service.

Billing and submission instructions

Bill on CMS 1500 (02-12), UB-04, or 837 equivalent claim form.
Follow Medicare Advantage PPO unique billing requirements and report CPT/HCPCS and diagnosis codes to the highest level of specificity.
Include your National Provider Identifier (NPI) on all claims and use electronic billing where available; Michigan providers can access ANSI ASC X12N 837/835 companion documents on the Blue Cross website; providers outside Michigan should contact their local Blue Cross plan.
Send electronic and/or paper claims to your local Blue Cross plan; send paper claims to: Medicare Plus Blue Blue Cross Blue Shield of Michigan P.O. Box 32593 Detroit, MI 48232-0593.

Coverage Source and Provider Billing Guidance

Billing Rule

Coverage and payment sourcing — Group-determined reimbursement and maximums

Coverage and payment for HCPCS L8010 (mastectomy sleeve) is provided under the City of Livonia Medicare Plus Blue Group PPO plan; the Group determines the scope of the benefit, reimbursement methodology, maximum payment amounts, and member cost sharing. Providers must obtain the plan's maximum payment amount for Northwood providers from Northwood, Inc. or for non-Northwood providers from the Medicare Plus Blue Enhanced Benefits Fee Schedule on the provider website. Payment to the provider will be the lesser of the plan's maximum payment amount or the provider's charge, minus any member cost share; this payment represents payment in full and providers may not balance bill members for the difference.

For Northwood providers: obtain maximum payment amount by contacting Northwood, Inc. at provideraffairs@northwoodinc.com.
For non-Northwood providers: obtain maximum payment amount from the Medicare Plus Blue Enhanced Benefits Fee Schedule on the provider website.
Provider payment = lesser of plan maximum or provider charge, minus member cost share; no balance billing allowed.

Policy Definitions

Mastectomy sleeve — definition and clinical use.

DefinitionA mastectomy sleeve is a device commonly used to prevent and treat lymphedema following breast cancer surgery.

Clinical useUsed to reduce pain and severe swelling in the arm when lymphatic flow is disrupted after breast surgery.

Associated HCPCSL8010 (mastectomy sleeve)

Typical providerDME / Prosthetics and Orthotics supplier

Original Medicare coverage status — Original Medicare does not cover mastectomy sleeves as prostheses.

Original Medicare coverageOriginal Medicare does not cover mastectomy sleeves because they do not meet the definition of a prosthesis.

Medicare Advantage coverageMedicare Plus Blue Group PPO may cover mastectomy sleeves (L8010) as an enhanced benefit beyond Original Medicare.

Benefit determinationWhen Original Medicare does not cover, the group (City of Livonia Medicare Plus Blue) determines scope of benefit, reimbursement methodology, maximum payment amounts, and member cost sharing.