Physicians! Are You Ordering External Breast Prostheses and Supplies for Your Patient?

Following this guidance will help your patients and the Medicare program by verifying there is medical documentation to support the provision of external breast prostheses and supplies.

Medicare coverage requires the patient’s medical record to show a past mastectomy and a valid and complete order. Coverage includes supplies both at the time of the mastectomy and after.

The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier cannot submit a claim for reimbursement until a standard written order (SWO) is provided. The standard written order must contain the elements below. Help your patient by providing this timely.

  • Beneficiary's name or Medicare Beneficiary Identifier (MBI)
  • Order date
  • Description of the item(s) ordered
  • Quantity to be dispensed, if applicable
  • Treating practitioner’s name or NPI
  • Treating practitioner's signature

There must also be information in the patient’s medical record that justifies continued medical need, and it must be made available to the supplier or review contractor upon request.

The following may serve as documentation justifying continued medical need for the External Breast Prostheses and supplies:

  • A recent order by the treating physician for refills
    • Does not have to be the surgeon
    • Current treatment not necessarily related to the mastectomy; however, on-going care must be addressed
  • A recent change in prescription
  • Timely documentation in beneficiary’s medical record showing usage of item(s)
    • Defined as a record entered in preceding 12 months
    • Must indicate mastectomy or absence of breast
    • In absence of evidence of reconstruction, original mastectomy surgery documentation is sufficient to verify mastectomy

For coverage and limitations of these supplies review Local Coverage Determination (LCD) L33317 and Policy Articles A52478 and CMS Local Coverage Article A55426.