Facial Prostheses, External

Number: 0620

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses facial prostheses, external.

1. Medical Necessity

   Aetna considers superficial facial prosthesis and associated supplies medically necessary as per below:

   1. Superficial facial prosthesis when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect, regardless of whether the facial prosthesis restores function. See CPB 0031 - Cosmetic Surgery and Procedures;
   2. Adhesives, adhesive remover, and tape used in conjunction with a facial prosthesis. 

2. Policy Limitations and Exclusions

   Note: Other skin care products related to the prosthesis, including but not limited to cosmetics, skin cream, cleansers, etc., are not covered as they are not considered medical items.

3. Related Policies

   • CPB 0031 - Cosmetic Surgery and Procedures
   • For information on ocular prostheses that are not part of orbital prostheses, see CPB 0619 - Eye Prosthesis.

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
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
21088	facial prosthesis
HCPCS codes covered if selection criteria are met:
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
L8045	Auricular prosthesis, provided by a nonphysician
L8046	Partial facial prosthesis, provided by a nonphysician
L8047	Nasal septal prosthesis, provided by a nonphysician
L8048	Unspecified maxillofacial prosthesis, by report, provided by a nonphysician
L8049	Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments, provided by a nonphysician
V2623	Prosthetic eye, plastic, custom
V2624	Polishing/resurfacing of ocular prosthesis
V2625	Enlargement of ocular prosthesis
V2626	Reduction of ocular prosthesis
V2627	Scleral cover shell
V2628	Fabrication and fitting of ocular conformer
V2629	Prosthetic eye, other type
Modifier KM	Replacement of facial prosthesis including new impression/moulage
Modifier KN	Replacement of facial prosthesis using previous master model
HCPCS codes not covered for indications listed in the CPB:
A6250	Skin sealants, protectants, moisturizers, ointments, any type, any size
A6260	Wound cleansers, any type, any size
ICD-10 codes covered is selection criteria are met (not all-inclusive):
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 - Q67.4	Congenital deformities of skull, face, and jaw [absence of facial tissue]
Z90.01	Acquired absence of eye

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Background

This policy is based upon Medicare DME MAC policy.

An external nasal prosthesis is a removable superficial prosthesis that restores all or part of the nose.  It may include the nasal septum.

An 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 any intraoral maxillary component.  Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek, upper lip, or forehead.

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

An external upper facial prosthesis is a removable superficial prosthesis that restores the orbit plus significant adjacent facial tissue/structures, but does not include the nose or any intraoral maxillary component.  Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek or forehead.

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

An external auricular prosthesis is a removable superficial prosthesis that restores all or part of the ear.

A superficial partial facial prosthesis is a removable superficial prosthesis that restores a portion of the face but which does not specifically involve the nose, orbit or ear.

An external nasal septal prosthesis is a removable prosthesis that occludes a hole in the nasal septum but does not include superficial nasal tissue.

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Appendix 

Note: The following services and items are included in the allowance for a facial prosthesis and, therefore, are not separately reimbursed:

• Evaluation of the member
• Pre-operative planning
• Cost of materials
• Labor involved in the fabrication and fitting of the prosthesis
• Modifications to the prosthesis made at the time delivery of the prosthesis or within 90 days thereafter
• Repair due to normal wear or tear within 90 days of delivery
• Follow-up visits within 90 days of delivery of the prosthesis.

Modifications to a prosthesis are separately payable when they occur more than 90 days after delivery of the prosthesis and they are medically necessary because of a change in the member’s condition.

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References