Local Coverage Determination · DME MAC
L33738
Facial Prostheses
Version 18. CMS effective date 01/01/2020. CMS updated 02/14/2020. 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 facial prosthesis is covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect. A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. 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. For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary.
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
- A52463 · Facial Prostheses - Policy Article
HCPCS codes on this LCD
10 other Level II codes are on the LCD and are not given a page in this set: A4455, A4456, A5120, L8045, L8046, L8047, L8048, L8049, V2623, V2629.
Questions
What does LCD L33738 cover?
L33738 is Facial Prostheses. It is a current final DME MAC local coverage determination, version 18.
Where is the CMS source for L33738?
The Medicare Coverage Database page for LCD L33738 version 18.
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=A4364&as_of=2024-01-15&npi=1234567890&state=UT"