HCPCS · Medicare DME
BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, BILATERAL, ANY SIZE, ANY TYPE
Long description on the CMS LCD code table, this read.
Data read from the CMS Coverage API on 2026-10-13. The LCD version is the current final DME MAC LCD on that read. Text below is quoted from those CMS documents. Nothing here is a coverage rule Verzi wrote.
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33317 version 39, effective 10/01/2026. CMS LCD L33317.
Version 39. CMS effective date 10/01/2026. CMS updated 09/23/2026. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. None
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. The diagnosis code must be included on each claim for the prosthesis or related item. If the patient's medical condition changes, this should be documented by the patient's treating practitioner submitting a new order which explains the need for a different type of breast prosthesis. The order must be kept in the supplier's files but need not be submitted with the claim. Based on Social Security Act §1834(h)(5), for purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by the treating practitioner.
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
The signed answer is the receipt for this code on a date of service: the rule that was in force, with a hash you can replay. The call needs an API key. The source archive and as-of resolution are public.
curl -H "X-API-Key: $VERZI_API_KEY" \
"https://api.verzi.health/v1/rules/warrant?hcpcs=L8002&as_of=2024-01-15&npi=1234567890&state=UT"The current DME MAC LCD L33317, External Breast Prostheses, version 39, effective 10/01/2026.
If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.
Request a free API key and call the signed-answer endpoint with the HCPCS code, a date of service, the supplier NPI, and a state. The response is a receipt for the published rule on that date, not a guarantee of payment.