CurrentnorthwoodPolicy N/A

Facial prosthesis — Coverage criteria, coding, documentation, and limitations

Customize your policy alerts

Sign up for all northwood policy alerts

Know when northwood releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs coverage, coding, documentation, and limitations for facial prostheses and related supplies for Northwood members; applies to both Medicare (with cross-reference) and non‑Medicare members as described.

Policy Summary

Payernorthwood

PolicyFacial prosthesis — Coverage criteria, coding, documentation, and limitations

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 24, 2021

Last ReviewApr 11, 2025

Next Review DateNov 12, 2024

Key ActionSubmit a signed, dated treating practitioner order with each billed item and include documentation for replacement, repair, or modification.

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.

CurrentnorthwoodPolicy N/A

Facial prosthesis — Coverage criteria, coding, documentation, and limitations

Customize your policy alerts

Sign up for all northwood policy alerts

Know when northwood releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payernorthwood

PolicyFacial prosthesis — Coverage criteria, coding, documentation, and limitations

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 24, 2021

Last ReviewApr 11, 2025

Next Review DateNov 12, 2024

Key ActionSubmit a signed, dated treating practitioner order with each billed item and include documentation for replacement, repair, or modification.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysFollow-up allowance

L33738Medicare cross-ref

Multiple L-codesHCPCS codes

RT/LT since 3/1/19MA billing rule

Coverage Criteria

General Coverage Criteria

Covered when ALL of the following are met

Order & indication: Must be ordered by the member's treating practitioner.

See documentation requirements for order submission (order must be signed and dated).

Clinical indication: There is loss or absence of facial tissue due to disease, trauma, surgery or a congenital defect.

Supplies coverage: Adhesives, adhesive remover, skin barrier wipes, and tape used in conjunction with a facial prosthesis are covered.

See HCPCS list for billing codes.

Repairs and Replacement

Repair and replacement coverage conditions

Repairs are covered when there has been accidental damage or extensive wear to the prosthesis that can be repaired.

If the expense for repairs exceeds the estimated expense for a replacement prosthesis, no payment will be made for the amount of the excess.

Replacement is covered in cases of loss, irreparable damage or wear, or when required because of a change in the member's condition that cannot be accommodated by modification of the existing prosthesis.

When replacement requires a new impression/moulage rather than use of a prior master model, the reason must be clearly documented and submitted with the claim.

Ocular component billing: If an ocular prosthesis is dispensed as an integral part of a facial prosthesis, the ocular component must be billed by the provider of the facial prosthesis.

Refer to separate eye prosthesis policy for ocular prostheses that are not part of orbital prostheses.

Follow-up visits that occur more than 90 days after delivery and that do not involve modification or repair of the prosthesis are non‑covered. Skin care products related to the prosthesis (for example, cosmetics, skin creams, cleansers) are also non‑covered items.

Equipment that is used primarily and customarily for a non‑medical purpose is not considered durable medical equipment (DMEPOS) and therefore is not covered under this policy. Coverage determinations are made case‑by‑case and are subject to the member's contract terms, including medical necessity requirements; a finding that a product or service is reasonable and necessary does not by itself guarantee coverage under the member's plan.

Follow‑up visits occurring more than 90 days after delivery that do not include a documented modification or repair to the prosthesis are considered not medically necessary/non‑covered and may be denied.

All coverage determinations under this policy are subject to the member's contract language, including applicable exclusions, limitations, and medical necessity requirements. Providers must follow contract terms and obtain any required prior authorization; the determination that a DMEPOS product or service is reasonable and necessary does not itself establish coverage if the member's contract excludes or limits the item.

Coding and HCPCS/CPT

Covered HCPCS/Codes and relatedHCPCSCovered

A4364	ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PER OZ
A4450	TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES
A4452	TAPE, WATERPROOF, PER 18 SQUARE INCHES
A4455	ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE
A4456	ADHESIVE REMOVER, WIPES, ANY TYPE, EACH
A5120	SKIN BARRIER, WIPES OR SWABS, EACH
L8040	NASAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
L8041	MIDFACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
L8042	ORBITAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
L8043	UPPER FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN

1–10 of 19

1/2

HCPCS codes referenced for facial/ocular prosthesis billingHCPCS

V2623	Ocular prosthesis component (exact code reference in policy)
V2629	Ocular prosthesis component (other) (exact code reference in policy)
L8042	Facial prosthesis code referenced in RT/LT billing instructions
L8043	Facial prosthesis code referenced in RT/LT billing instructions
L8045	Facial prosthesis code referenced in RT/LT billing instructions
L8046	Facial prosthesis code referenced in RT/LT billing instructions

Tape unit definition — billing guidance

Unit definitionOne unit of tape = 18 square inches

Example — 1/2" x 3 ydsCounts as 3 units

Example — 1" x 3 ydsCounts as 6 units

Applicable HCPCS codesTape billed with A4450 (non-waterproof) or A4452 (waterproof)

Provider Actions, Documentation & Billing

Prior Authorization

Practitioner order and claim submission

Items must be ordered by the member's treating practitioner; an order signed and dated by the treating practitioner must be submitted with the claim.

Prior Authorization

Prior authorization and medical necessity

Coverage determinations are made case-by-case and are subject to all terms, conditions, limitations, and exclusions of the member's contract, including medical necessity; providers should follow contract and medical necessity requirements for prior authorization when applicable.

Documentation Required

Order and reason must accompany claims for services

Background

A facial prosthesis is a removable device used to restore all or part of facial structures lost due to disease, trauma, surgery, or congenital defect. Components may include nasal, orbital, auricular, midfacial, upper facial, hemi‑facial, partial, or nasal septal prostheses. An ocular prosthesis component may be included when integral to the facial prosthesis but must be billed and documented according to the policy when provided as a distinct component.

Definitions

Facial prosthesis — definition & specifics

DefinitionA facial prosthesis is a removable device used to restore all or part of facial structures lost due to disease, trauma, surgery, or a congenital defect.

ComponentsMay include nasal, orbital, auricular, midfacial, upper facial, hemi-facial, partial, or nasal septal prostheses; ocular components may be included when integral.

Supply coverageAdhesives, adhesive remover, tape, and skin barrier wipes used in conjunction with a facial prosthesis are billable using listed HCPCS codes when appropriate.

Ocular prosthesis — custom vs stock and billing

Ocular prosthesis typesCustom ocular prosthesis: V2623; Stock (non-custom) ocular prosthesis: V2629.

Billing when integral to facial prosthesis

Revision History

2006-11Initial release

Policy initially released (prepared/reviewed by Rosanne Brugnoni; approved by Ken Fasse).

2007-07Billing code revision

Revised requirements for billing codes L8048 and V2629.

2009-07Modifier instructions revised

Revised RT/LT modifier instructions.

Policy Summary

Payernorthwood

PolicyFacial prosthesis — Coverage criteria, coding, documentation, and limitations

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 24, 2021

Last ReviewApr 11, 2025

Next Review DateNov 12, 2024

Key ActionSubmit a signed, dated treating practitioner order with each billed item and include documentation for replacement, repair, or modification.

SourceLink

On This Page

Submit an order signed and dated by the treating practitioner with each billed item; include explanations when billing for replacement, repair, or modification to document the reason for the service.

A separate practitioner order is not required for subsequent modifications, repairs, or replacement of the same facial prosthesis unless different supplies are ordered.
Claims for replacement, repair, or modification must include an explanation of the reason for the service.

Documentation Required

Supporting documentation for miscellaneous and stock ocular codes

When miscellaneous code L8048 or stock ocular code V2629 is used, include the required descriptive documentation with the claim (description and drawing/photo for L8048; complete item description for V2629).

L8048 — accompany claim with clear description and drawing or photograph and medical necessity.
V2629 — accompany claim with a complete description of the item.

Documentation Required

Required orders and supporting documentation

An order signed and dated by the treating practitioner must be submitted with each billed item; claims for replacement, repair, or modification must include supporting documentation and an explanation of the reason for the service.

A new order is required when different supplies are ordered.
When additional documentation is required, it should be submitted with the claim.

Billing Rule

RT/LT modifiers and unit documentation

Document RT and LT on the claim when applicable; for Medicare Advantage DOS on or after 3/1/2019, bill bilateral items using separate claim lines with RT and LT modifiers and 1 unit on each line — do not use RTLT on the same line with 2 units.

If bilateral prostheses using the same code are provided on the same DOS, submit two claim lines: one with RT and 1 unit, one with LT and 1 unit.
Do not bill RTLT on the same claim line with 2 units for these items.

Denial Risk

Non-covered late follow-up visits (>90 days)

Follow-up visits occurring more than 90 days after delivery that do not involve modification or repair are non-covered and may be denied.

Modifications, repairs, and follow-up visits within 90 days of delivery are included in the allowance and not separately billable.
Modifications more than 90 days after delivery may be separately payable if required due to a change in the member's condition.

Denial Risk

Incorrect RT/LT coding triggers rejection

Claims billed with codes L8042-L8043 and L8045-L8046 without RT and/or LT modifiers, or with RTLT on the same claim line billed with 2 units of service, will be rejected as incorrect coding.

Ensure RT or LT modifiers are present on individual claim lines for these codes when applicable.
Avoid billing RTLT with 2 units on a single line for bilateral services.

When a new ocular prosthesis component is provided as an integral part of an orbital, upper facial, or hemi-facial prosthesis, it should be billed using V2623 or V2629 on a separate claim line.

When not billedIf the replacement facial prosthesis reuses the ocular component from the prior prosthesis, do not bill the ocular code separately.

Durable Medical Equipment (DMEPOS) — definition & exclusion

DefinitionDurable Medical Equipment (DMEPOS) refers to equipment used primarily and customarily for medical purposes.

Non-medical exclusionEquipment used primarily and customarily for a non-medical purpose is not considered DMEPOS and is excluded from coverage.

Coverage determinationsDeterminations are case-by-case and subject to the member's contract terms, limitations, and medical necessity requirements.

2009-12-22Annual review / code added

Annual review with addition of a code (annual review noted Dec 22, 2009).

2010-01-05Code update

Added A4456 for adhesive remover (wipes); discontinued A4365 and set limit of 50 each.

2011-11-08Annual review

Annual review and added references to policy (Nov 2011).

2012-11-28Annual review

Annual review completed with no changes (Nov 28, 2012).

2013-12-30Annual review

Annual review completed with no changes (Dec 30, 2013).

2014-11-24Annual review

Annual review completed with no changes (Nov 24, 2014).

2017-11-14Annual review

Annual review completed with no changes (Nov 14, 2017).

2018-11-13Annual review

Annual review completed with no changes (Nov 13, 2018).

2019-11-11Billing requirement clarification

Updated billing requirements for Medicare Advantage to require bilateral RT/LT services billed on separate claim lines (effective Nov 2019).

2020-11-09Terminology and formatting update

Revised term 'treating physician' to 'treating practitioner' and changed HCPCS references from code spans to individually listed codes (Nov 9, 2020).

2021-11-24Medicare reference added

Added NCD and LCD verbiage to the 'Important Note' section (Nov 24, 2021).

2022-11-14Annual review

Annual review completed with no changes (Nov 14, 2022).

2023-11-09Annual review

Annual review completed with no changes (Nov 9, 2023).

2024-11-12Annual review

Annual review completed with no changes (Nov 12, 2024).

2025-11-04Annual review / reference updateLatest

Annual review with updated reference (Nov 4, 2025).