CurrentmediviewcurativePolicy MM-PNP-057

External Breast Prosthesis (Mastectomy Bra and Prosthesis) Coverage Criteria

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Policy governing medical necessity and authorization for external breast prostheses and related garments for members following mastectomy, lumpectomy, or for patients with gender dysphoria; used by the Medical Utilization Management department.

Policy Summary

Payermediviewcurative

PolicyExternal Breast Prosthesis (Mastectomy Bra and Prosthesis) Coverage Criteria

Policy CodePolicy MM-PNP-057

Change TypeNo material changes

Effective DateApr 12, 2024

Next Review Date

Key ActionObtain prior authorization for external breast prosthesis services per Medical UM processes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Up to 6mastectomy bras allowed initially or per year

1 per sidebreast prosthesis allowed for useful lifetime

24 monthssilicone replacement interval

6 monthsfabric/foam/fiber replacement

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CurrentmediviewcurativePolicy MM-PNP-057

External Breast Prosthesis (Mastectomy Bra and Prosthesis) Coverage Criteria

Customize your policy alerts

Sign up for mediviewcurative Policy MM-PNP-057 alerts

Get alerted when Policy MM-PNP-057 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

Payermediviewcurative

PolicyExternal Breast Prosthesis (Mastectomy Bra and Prosthesis) Coverage Criteria

Policy CodePolicy MM-PNP-057

Change TypeNo material changes

Effective DateApr 12, 2024

Next Review Date

Key ActionObtain prior authorization for external breast prosthesis services per Medical UM processes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Up to 6mastectomy bras allowed initially or per year

1 per sidebreast prosthesis allowed for useful lifetime

24 monthssilicone replacement interval

6 monthsfabric/foam/fiber replacement

3 monthsnipple prosthesis replacement

Coverage and Medical Necessity Criteria

Medical necessity and coverage criteria

Covered when ANY of the following are met:

Primary indications: Following a medically necessary mastectomy or lumpectomy; or for patients with gender dysphoria.

Initial prosthesis and bras: An initial external breast prosthesis and up to four initial mastectomy bras are covered following a medically necessary mastectomy or for patients with gender dysphoria; for mastectomy patients, 'initial' applies to items purchased within one year after the mastectomy.

Mastectomy bras generally covered: Up to six mastectomy bras (breast prosthesis bras) are considered medically necessary; up to six mastectomy bra replacements every 12 months.

Prosthesis quantity and replacement intervals: Only one external breast prosthesis per side for the useful lifetime; two prostheses (one per side) for members with bilateral mastectomies or for members with gender dysphoria; silicone prosthesis replacement allowed every 24 months; fabric/foam/fiber prosthesis replacement allowed every 6 months; nipple prosthesis replacement allowed every 3 months; medical necessity for more frequent replacements must be documented.

Post‑operative garment and alternative use: An external breast prosthesis garment with mastectomy form is covered for use in the post‑operative period prior to a permanent prosthesis, or as an alternative to a mastectomy bra and breast prosthesis, and for members with gender dysphoria.

A breast prosthesis that incorporates an integrated adhesive ("silicone or equal, with integrated adhesive") is considered not medically necessary. The policy states such devices have not been demonstrated to provide clinical advantage over prostheses without integrated adhesive and therefore will not be covered.

Custom-fabricated prostheses may be provided when clinically required; however, the policy explicitly states that the additional features of custom-fabricated prostheses beyond a prefabricated silicone prosthesis are not considered medically necessary. Requests for prostheses with integrated adhesive or for custom features that exceed the clinical value of prefabricated silicone prostheses will be denied as not medically necessary.

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior authorization required for external breast prosthesis

Prior authorization is required for external breast prosthesis services and must follow the Medical Utilization Management processes used to inform medical necessity and authorization decisions.

Step Therapy

No step therapy requirements

This policy specifies no step therapy requirements for external breast prostheses.

Documentation Required

Document clinical indication and timing

Definitions

Mastectomy bra without integrated form: definition and description

DefinitionA mastectomy bra without integrated form is a bra with pockets intended to hold a mastectomy form or breast prosthesis held adjacent to the chest wall; it does not include an integrated breast prosthesis.

Materials and constructionMay be constructed of any material (e.g., cotton, polyester, or other materials), any size, any type or location of closure, and may have integrated structural support (e.g., underwire).

Intended useDesigned to retain a separate mastectomy form or prosthesis in the pocket(s) adjacent to the chest wall following mastectomy or lumpectomy or for gender-affirming use.

VariationsAvailable in multiple sizes and styles; pockets accommodate unilateral or bilateral prosthetic forms; does not contain a permanently attached prosthesis.

Mastectomy bra with integrated form: definition and description

Background

Curative covers external breast prostheses and related garments when clinically indicated following a medically necessary mastectomy or lumpectomy, or for members with gender dysphoria. Coverage includes an initial external breast prosthesis and mastectomy bras purchased within one year after the mastectomy, and ongoing replacements subject to specified intervals and quantity limits. Specifically, mastectomy bras are limited to up to six and may be replaced up to six times every 12 months; an external breast prosthesis is limited to one per side for the useful lifetime (or two total for bilateral mastectomy or gender dysphoria). Replacement intervals are every 24 months for silicone prostheses, every 6 months for fabric/foam/fiber prostheses, and every 3 months for nipple prostheses. An external breast prosthesis garment with mastectomy form is covered for post-operative use prior to a permanent prosthesis or as an alternative to a mastectomy bra and prosthesis, and for members with gender dysphoria.

Policy Summary

Payermediviewcurative

PolicyExternal Breast Prosthesis (Mastectomy Bra and Prosthesis) Coverage Criteria

Policy CodePolicy MM-PNP-057

Change TypeNo material changes

Effective DateApr 12, 2024

Next Review Date

Key ActionObtain prior authorization for external breast prosthesis services per Medical UM processes.

SourceLink

On This Page

Document the medical indication for the prosthesis or mastectomy bra — specifically that it follows a medically necessary mastectomy or lumpectomy or is for gender dysphoria — and the timing (e.g., initial purchases within one year after mastectomy for mastectomy-related items).

Support that the item is following a medically necessary mastectomy or lumpectomy or is for gender dysphoria.
Indicate timing for mastectomy-related initial purchases (within one year after the mastectomy).

Denial Risk

Denial risk for integrated-adhesive silicone prostheses

Requests for silicone (or equal) breast prostheses with integrated adhesive are considered not medically necessary and would be denied.

Integrated-adhesive silicone prostheses lack demonstrated clinical advantage and are excluded.
Additional custom-fabricated features beyond prefabricated silicone are not considered medically necessary.

A mastectomy bra with integrated form is a bra that includes an integrated unilateral or bilateral breast prosthesis form; the prosthesis is incorporated into the garment.

ScopeDescribed as unilateral or bilateral, any size or type; the integrated prosthetic form is part of the bra rather than a separate insert.

Use casesIntended for members needing an integrated prosthetic contour post-mastectomy, lumpectomy, or for gender-affirming care when an integrated form is preferred.

Custom molded prosthesis: custom fabricated prosthesis definition

DefinitionA custom molded prosthesis (custom fabricated prosthesis molded to patient model) is an individually made prosthesis created by taking an impression of the chest wall to make a positive model, on which the prosthesis is molded.

ProcessBegins with making an impression of the patient’s chest wall; the impression is used to create a positive model; the prosthesis is then molded on that positive model.

IndicationUsed when an individually made prosthesis is required to match chest wall anatomy or when prefabricated options are inadequate.

ClassificationConsidered a type of custom fabricated prosthesis produced from basic materials and individually tailored to the patient.