High impact
External Breast Prosthesis (CPB 0097, reviewed 2026-01-15)
Aetna·Effective Jan 15, 2026
Aetna updated its External Breast Prosthesis policy (CPB 0097) effective 2026-01-15, establishing coverage criteria for mastectomy-related prosthetics and gender dysphoria cases. Key changes include explicit coverage for up to 6 mastectomy bras, silicone prostheses with specified replacement schedules (every 24 months for silicone, every 6 months for fabric/foam, every 3 months for nipple prostheses), and lymphedema compression sleeves. The policy explicitly excludes prostheses with integrated adhesive and custom-fabricated prostheses, and requires Standard Written Orders (SWOs) with complete medical documentation before claims submission to prevent denials.