Local Coverage Determination · DME MAC
L33317
External Breast Prostheses
Version 39. CMS effective date 10/01/2026. CMS updated 09/23/2026. Read from the CMS Coverage API on 2026-10-13. Contractors on the report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation. None
Coverage indication
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. The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section. Refer to the Supplier Manual for additional information on documentation requirements. Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD. For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity. A breast prosthesis is covered for a patient who has had a mastectomy. (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses.) An external breast prosthesis garment, with mastectomy form (L8015) is covered for use in the postoperative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis. Breast prostheses, silicone or equal, with integral adhesive (L8031) have not been demonstrated to have a clinical advantage over those without the integral adhesive. Therefore, if L8031 is billed, it will be denied as not reasonable and necessary.
Excerpt from the LCD indication. Full text on CMS.
Documentation requirements
Items covered in this LCD have additional policy-specific requirements that must be met prior to Medicare reimbursement. Refer to the LCD-related Policy article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information.
Related articles
- A55426 · Standard Documentation Requirements for All Claims Submitted to DME MACs
- A52478 · External Breast Prostheses - Policy Article
HCPCS codes on this LCD
5 other Level II codes are on the LCD and are not given a page in this set: L8031, L8032, L8033, L8035, L8039.
Questions
What does LCD L33317 cover?
L33317 is External Breast Prostheses. It is a current final DME MAC local coverage determination, version 39.
Where is the CMS source for L33317?
The Medicare Coverage Database page for LCD L33317 version 39.
Get the signed answer via API
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=A4280&as_of=2024-01-15&npi=1234567890&state=UT"