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Reimbursement
The Women’s Health and Cancer Rights Act of 1998 (WHCRA) includes protection for individuals who elect breast reconstruction in connection with a mastectomy. WHCRA requires that group health plans and health insurance issuers that provide coverage for medical and surgical benefits with respect to mastectomies must also cover certain post-mastectomy benefits, including reconstructive surgery and the treatment of complications such as lymphedema. Most plans recognize non-surgical reconstruction as well, i.e. breast prostheses as a post-mastectomy benefit.
To maximize coverage for custom prostheses, it is important to file the following with the claim:
Cover letter to insurance carrier or Medicare
Actual Claim (standard Custom insurance reimbursement code is L8035)
Physicians Prescription
Letter of Medical Necessity (pdf)
Photographs of chest wall
The standard off-the-shelf prosthesis insurance reimbursement code is L8030.
The temporary prosthesis insurance reimbursement code is L8020.
Note: ContourMed is not responsible for claim submission, correct coding, or reimbursement. Health plans vary and it is recommended you contact your health plan provider for more information or submit a preauthorization to determine benefits if you are unsure of your plan coverage.