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#Bellisse compression bra skin#
#Bellisse compression bra code#

HCPCS codes covered if selection criteria are met:Īdhesive skin support attachment for use with external breast prosthesis, each Codes requiring a 7th character are represented by "+": Information in the below has been added for clarification purposes.

#Bellisse compression bra code#

Table: Applicable CPT / HCPCS / ICD-10 Codes Code

More than one external breast prosthesis.

Note: The additional features of a custom-fabricated breast prosthesis, compared to a pre-fabricated silicone breast prosthesis, are not considered medically necessary. Note: The Women's Health and Cancer Rights Act (WHCRA) of 1998 (Public Law #105-277) mandates that all insurance companies provide coverage for breast "prostheses and physical complications of mastectomy including lymphedemas."Īetna considers the following not medically necessary:Ī breast prosthesis, silicone or equal, with integrated adhesive is considered not medically necessary because it has not been demonstrated to have a clinical advantage over those without the integrated adhesive. Three gradient compression lymphedema sleeves ("mastectomy sleeves") initially per affected arm, then two replacements every six months. Please check benefit plan descriptions for details. Note: Some Aetna plans limit coverage to an initial breast prosthesis and do not cover replacement prostheses.

The medical necessity of more frequent replacements must be documented.

Replacements of nipple prostheses are considered medically necessary every 3 months.

For fabric, foam, or fiber-filled breast prostheses, replacements are considered medically necessary every 6 months.

One replacement silicone breast prostheses every 24 months:.

Members who have had bilateral mastectomies or.

Two breast prostheses, one per side, for:.

Only one breast prosthesis per side for the useful lifetime of the prosthesis.

Use in the post-operative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis or.

An external breast prosthesis garment with mastectomy form for:.

Up to four breast prosthesis bra (mastectomy bra) replacements every 12 months.

For persons who have had a mastectomy, "initial" applies to a breast prosthesis and bras purchased within one year after the mastectomy is performed, not the first breast prosthesis prescribed after the member's Aetna coverage becomes effective. Under these plans, an initial external breast prosthesis and up to four initial breast prosthesis bras (mastectomy bras) are covered following a medically necessary mastectomy or for persons with gender dysphoria. Note: Some Aetna plans limit prosthetic coverage to an initial medically necessary prosthesis and do not cover replacement prostheses. For members who have a medically necessary mastectomy form or silicone (or equal) breast prosthesis when the pocket of the bra is used to hold the form/prosthesis or.Initially following a medically necessary mastectomy or.Up to four breast prosthesis bras (mastectomy bras): Following a medically necessary mastectomy orĪetna considers the following medically necessary:.This Clinical Policy Bulletin addresses external breast prosthesis.Īetna considers external breast prosthesis medically necessary: View knee high, thigh high and waist high compression socks and stockings, designed for pressure support and shop our wide range of compression socks and stockings with Independence Australia.Number: 0097 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References

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