Dental Policy Bulletins

Number: 026
(Updated)

Subject: Facial Prostheses, External

Reviewed: September 23, 2013

Important Note

This Clinical Policy Bulletin expresses our determination of whether certain services or supplies are medically necessary. We have reached these conclusions based on a review of currently available clinical information including:
  • Clinical outcome studies in the peer-reviewed published medical and dental literature
  • Regulatory status of the technology
  • Evidence-based guidelines of public health and health research agencies
  • Evidence-based guidelines and positions of leading national health professional organizations
  • Views of physicians and dentists practicing in relevant clinical areas
  • Other relevant factors
We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.

Policy

Aetna considers a superficial facial prosthesis medically necessary when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect, regardless of whether the facial prosthesis restores function.  See CPB 0031 - Cosmetic Surgery.

Aetna considers adhesives, adhesive remover, and tape used in conjunction with a facial prosthesis medically necessary. Note: Other skin care products related to the prosthesis, including but not limited to cosmetics, skin cream, cleansers, etc., are not covered as they are not considered medical items.

Note: For information on ocular prostheses that are not part of orbital prostheses, see CPB 0619 - Eye Prosthesis.

Background

This policy is based upon Medicare DMERC policy.

An external nasal prosthesis is a removable superficial prosthesis that restores all or part of the nose. It may include the nasal septum.

An external mid-facial prosthesis is a removable superficial prosthesis that restores part or all of the nose plus significant adjacent facial tissue/structures, but does not include the orbit or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek, upper lip or forehead.

An external orbital prosthesis is a removable superficial prosthesis that restores the eyelids and the hard and soft tissue of the orbit. It may also include the eyebrow. An orbital prosthesis may or may not include the ocular prosthesis component.

An external upper facial prosthesis is a removable superficial prosthesis that restores the orbit plus significant adjacent facial tissue/structures, but does not include the nose or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek or forehead.

An external hemi-facial prosthesis is a removable superficial prosthesis that restores part or all of the nose plus the orbit plus significant adjacent facial tissue/structures, but does not include any intraoral maxillary component.

An external auricular prosthesis is a removable superficial prosthesis that restores all or part of the ear.

A superficial partial facial prosthesis is a removable superficial prosthesis that restores a portion of the face but which does not specifically involve the nose, orbit or ear.

An external nasal septal prosthesis is a removable prosthesis that occludes a hole in the nasal septum but does not include superficial nasal tissue.

CPT Codes / HCPCS Codes / ICD-9 Codes*
CPT codes covered if selection criteria are met:
21076 Impression and custom preparation; surgical obturator prosthesis
21077 orbital prosthesis
21079 interim obturator prosthesis
21080 definitive obturator prosthesis
21081 mandibular resection prosthesis
21082 palatal augmentation prosthesis
21083 palatal lift prosthesis
21085 oral surgical splint
21086 auricular prosthesis
21087 nasal prosthesis
21088 facial prosthesis
HCPCS codes covered if selection criteria are met:
A4364 Adhesive, liquid, or equal, any type, per oz.
A4365 Adhesive remover wipes, any type, per 50
A4450 Tape, non-waterproof, per 18 sq. in.
A4452 Tape, waterproof, per 18 sq. in.
A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per oz.
L8040 Nasal prosthesis, provided by a nonphysician
L8041 Midfacial prosthesis, provided by a nonphysician
L8042 Orbital prosthesis, provided by a nonphysician
L8043 Upper facial prosthesis, provided by a nonphysician
L8044 Hemi-facial prosthesis, provided by a nonphysician
L8045 Auricular prosthesis, provided by a nonphysician
L8046 Partial facial prosthesis, provided by a nonphysician
L8047 Nasal septal prosthesis, provided by a nonphysician
L8048 Unspecified maxillofacial prosthesis, by report, provided by a nonphysician
L8049 Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments, provided by a nonphysician
V2623 Prosthetic eye, plastic, custom
V2624 Polishing/resurfacing of ocular prosthesis
V2625 Enlargement of ocular prosthesis
V2626 Reduction of ocular prosthesis
V2627 Scleral cover shell
V2628 Fabrication and fitting of ocular conformer
V2629 Prosthetic eye, other type
Modifier KM Replacement of facial prosthesis including new impression/moulage
Modifier KN Replacement of facial prosthesis using previous master model
HCPCS codes not covered for indications listed in the CPB:
A6250 Skin sealants, protectants, moisturizers, ointments, any type, any size
A6260 Wound cleansers, any type, any size
ICD-9 codes covered is selection criteria are met (not all-inclusive):
743.00 Anophthalmos, congenital absence of eye
744.01 Absence of external ear
744.09 Other anomaly of ear causing impairment of hearing [absence of ear, congenital]
744.21 Absence of ear lobe, congenital
744.89 Other specified anomalies of face and neck [loss of facial tissue]
748.1 Other anomalies of nose [absent nose]
754.0 Congenital anomalies of skull, face, and jaw [absence of facial tissue]
V45.78 Acquired absence of organ, eye
Other ICD-9 codes related to the CPB:
738.0 Acquired deformity of nose
743.62 Congenital deformities of eyelids
743.66 Specified congenital anomalies of orbit
743.69 Other congenital anomalies of eyelids, lacrimal system, and orbit
744.29 Other specified anomalies of ear

The above policy is based on the following references:

  1. NHIC, Corp. Facial prosthesis. Local Coverage Determination No. L5046. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised January 1, 2010.
  2. NHIC, Corp. Facial prosthesis. Local Policy Article No. A25186. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised January 2010.
  3. Roumanas ED, Freymiller EG, Chang TL, et al. Implant-retained prostheses for facial defects: An up to 14-year follow-up report on the survival rates of implants at UCLA. Int J Prosthodont. 2002;15(4):325-332.
  4. Chang TL, Garrett N, Roumanas E, Beumer J 3rd. Treatment satisfaction with facial prostheses. J Prosthet Dent. 2005;94(3):275-280.
  5. Hooper SM, Westcott T, Evans PL, et al. Implant-supported facial prostheses provided by a maxillofacial unit in a U.K. regional hospital: Longevity and patient opinions. J Prosthodont. 2005;14(1):32-38.

Revision Dates

Original policy: November 4, 2004
Updated: September 25, 2006, August 26, 2008; November 16, 2009; January 20, 2011; June 5, 2012; September 23, 2013
Revised:
Medical Policy Bulletin #0620: October 5, 2012

http://aetnet.aetna.com/mpa/cpb/600_699/0620.html

This CPB has been updated with additional references.



Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

*Current Procedural Terminology (CPT®) 2010 copyright
2010 American Medical Association. All Rights Reserved.

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