External Breast Prosthesis (CPB 0097, reviewed 2026-01-15)

By 2026-01-15: Billing team must implement the following changes: (1) Update billing system to require Standard Written Orders (SWOs) for ALL breast prosthesis and compression sleeve claims before submission—claims submitted without completed SWOs will be denied as not medically necessary. (2) Configure system to block billing for non-covered codes L8031 (integrated adhesive prosthesis) and L8035 (custom-fabricated prosthesis) and reject these as not medically necessary. (3) Update claim scrubbing rules to enforce replacement frequency limits: L8030 every 24 months, L8020/L8010 every 6 months for fabric/foam, L8032 every 3 months for nipple prostheses, and A6522/A6523/A6574-A6578/A6584/A6588 every 6 months for compression sleeves. (4) Modify encounter forms and prior auth templates to require providers and staff to document: medical necessity in patient medical record (not supplier statements alone), evidence of prior mastectomy or gender dysphoria diagnosis, and date of prior prosthesis/replacement (to track 24/6/3-month intervals). (5) Ensure SWO process captures treating practitioner NPI, all base items, accessories, and supplies with individual HCPCS codes and quantities. (6) Train billing, prior auth, and clinical staff on strict SWO requirements and prohibition on supplier-prepared statements as sole documentation. Failure to implement SWO requirement will result in claim denials; claims for L8031 and L8035 will be systematically denied; and claims exceeding replacement frequency limits will be denied.