L11556-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Facial Prostheses (L11556)

Contractor Information

Contractor Name CGS Administrators, LLC

Contractor Number 18003

Contractor Type

DME MAC

Jurisdiction

J - G

LCD Information

Document Information

LCD ID Number L11556

LCD Title Facial Prostheses

Contractor's Determination Number FACE

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Alabama Arkansas Colorado Florida Georgia Louisiana Mississippi North Carolina New Mexico Oklahoma Puerto Rico

South Carolina Tennessee Texas

Virginia

Virgin Islands West Virginia

Oversight Region Region IV

DME Region LCD Covers Jurisdiction C

Original Determination Effective Date

For services performed on or after 11/01/1996 Original Determination Ending Date

Revision Effective Date

For services performed on or after 08/05/2011

Revision Ending Date

CMS National Coverage Policy None

Indications and Limitations of Coverage and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

A facial prosthesis is covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

AV – Item furnished in conjunction with a prosthetic device, prosthetic or orthotic.

EY – No physician or other licensed health care provider order for this item or service. KM - Replacement of facial prosthesis including new impression/moulage.

KN - Replacement of facial prosthesis using previous master model. LT - Left side

RT - Right side

HCPCS CODES:

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 L8044 HEMI-FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN L8045 AURICULAR PROSTHESIS, PROVIDED BY A NON-PHYSICIAN

L8046 PARTIAL FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN L8047 NASAL SEPTAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN

L8048 UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT, PROVIDED BY A NON-PHYSICIAN

L8049 REPAIR OR MODIFICATION OF MAXILLOFACIAL PROSTHESIS, LABOR COMPONENT, 15 MINUTE INCREMENTS, PROVIDED BY A NON-PHYSICIAN

V2623 PROSTHETIC EYE, PLASTIC, CUSTOM V2629 PROSTHETIC EYE, OTHER TYPE

ICD-9 Codes that Support Medical Necessity Not specified.

AsteriskNoteText

Diagnoses that Support Medical Necessity Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity Not specified.

General Information

Documentations Requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider". It is expected that the patient’s medical records will reflect the need for the care provided. The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

A separate physician order is not required for subsequent modifications, repairs, or replacement of a facial prosthesis. A new order is required when different supplies are ordered.

When either code V2629 or L8048 is billed, the claim must be accompanied by a brief description of the item in the narrative field. When L8048 is provided, a drawing/photograph of the item provided must be available upon request.

Refer to the Supplier Manual for more information on documentation requirements.

Appendices

Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision Advisory Committee Meeting Notes

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/1996

Revision History Number 007

Revision History Explanation Revision Effective Date: 01/01/2010 HCPCS CODES AND MODIFIERS:

Replaced: A4365 with A4456

Revision Effective Date: 11/15/2009

CPT/HCPCS code A4365 was deleted from group 1

Revision Effective Date: 03/01/2008

In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) LCD L11517 from DME PSC TrustSolutions (77012) LCD L11517.

Revision Effective Date: 07/01/2007 INDICATIONS AND LIMITATIONS OF COVERAGE:

Removed: DMERC references DOCUMENTATION REQUIREMENTS:

Removed: DMERC references

Revised: Requirements for billing codes L8048 and V2629

Revision Effective Date: 06/01/2007

In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

Revision Effective Date: 03/01/2006

In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revision Effective Date: 01/01/2006 HCPCS CODES AND MODIFIERS:

Added: A5120 Deleted: A5119

Revision Effective Date: 10/01/2005 HCPCS CODES AND MODIFIERS: Added: A5119, AV

Revision Effective Date 04/01/2005

LMRP converted to LCD and Policy Article

Revision Effective Date 04/01/2003 HCPCS CODES AND MODIFIERS:

Added: AV and EY modifiers, A4450, A4452 Deleted: K0572, K0573

INDICATIONS AND LIMITATIONS OF COVERAGE:

Adds standard language concerning coverage of items without an order

CODING GUIDELINES:Moved HCPCS definition to this section, Added instruction for the AV modifier DOCUMENTATION REQUIREMENTS:Adds standard language concerning use of EY modifier for items without an order

The revision date listed below is the date the revision was published and not necessarily the effective date for the revision.

07/01/2002 - Added codes A4364, A4365, K0572, K0573, L8040-L8049. Deleted codes K0440-K0449, K0265, K0450,

K0451. Added LT and RT modifiers.

08/05/2011 - The Jurisdiction C contractor adopted a new business name. This LCD revision only includes the change from CIGNA Government Services to CGS Administrators, LLC. No coverage information was included in this revision and no provider action is needed regarding this revision.

Reason for Change Maintenance (annual review with new changes, formatting, etc.)