Facial Prostheses - Policy Article - Effective October 2015

Revision Effective Date: 01/01/2020
CODING GUIDELINES:
Added: “Prosthetic devices that are custom fabricated for the individual beneficiary are not solely restricted to standard methods of fabrication and can include alternative fabrication methods (e.g., additive manufacturing). Correct coding of custom fabricated items includes compliance with the HCPCS long description of the individual HCPCS code, along with any other published coding guidelines.” as clarification


09/18/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: “Based on Social Security Act §1834(h)(5), for purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by the treating practitioner.” as clarification


04/03/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
Removed: “Claims for facial prostheses from nonphysicians provided in an office or nursing home setting are submitted to the DME MAC. Claims for facial prostheses from physicians in these settings are submitted to the local carrier.”
Added: “Physicians who are enrolled as a DMEPOS supplier are to submit claims for eye prostheses provided in an office or nursing home setting by nonphysicians or physicians to the DME MAC.”
Revised: “local intermediary” to “applicable A/B MAC”
Removed: “Implanted prosthesis anchoring components should not be billed to the DME MAC.” due to redundancy


03/21/2024: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Revised: “provides” to “provide”
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list


04/14/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Modifiers section and related information for modifiers AV, KM, KN, RT and LT
CODING GUIDELINES:
Removed: KM and RT/LT modifier instructions. Relocated to Modifiers section within Policy Specific Documentation Requirements


03/25/2021: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “physician’s” to “treating practitioner’s”
CODING GUIDELINES:
Revised: Format of HCPCS code references, from code spans to individually-listed HCPCS
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”


02/20/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 03/01/2019


CODING GUIDELINES:
Revised: RT and LT modifier billing instructions


02/07/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2018


Added: Clarifying language regarding use of miscellaneous code L8048


04/12/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2017
Added: Policy specific documentation requirements from Documentation section of LCD
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

Revision Effective Date: 07/01/2016
Updated: Title to remove effective date

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.

Revision Effective Date: 08/01/2015
NON-MEDICAL NECESSITY COVERAGE & PAYMENT RULES:
Revised: Language for HCPCS codes A4450, A4452, A5120, that are billed without correct modifier