Facial Prostheses, External (CPB 0620, reviewed 2025-12-11)

By December 11, 2025 (effective immediately): (1) Billing team must update claim submission guidelines to recognize CPT codes 21076-21088 and HCPCS codes L8040-L8049 as covered when medical necessity criteria are met (tissue loss from disease, trauma, surgery, or congenital defect). (2) Configure billing system to bundle evaluation, pre-operative planning, fabrication, fitting, and modifications within 90 days of delivery into the prosthesis allowance—do NOT bill separately. (3) After 90 days, set system to allow separate billing for modifications only if medically necessary due to change in patient condition. (4) Reject or correct any claims including A6250 (skin sealants/protectants) or A6260 (wound cleansers) as these are non-covered cosmetic/skincare items. (5) Train billing staff to verify ICD-10 diagnosis codes match covered indications (Q-codes for congenital defects, Z90.01 for acquired eye absence, etc.). (6) Apply modifiers KM (new impression) and KN (previous model) correctly for replacement prostheses. (7) Update encounter templates and prior authorization requests to reflect this policy. Failure to bundle services or to exclude non-covered skincare codes will result in claim denials and potential overpayment recovery.