Aetna Commercial Clinical Policy

Aetna External Breast Prosthesis Form

Effective Date

01/12/1996

Last Reviewed

03/21/2023

Original Document

  Reference



Background for this Policy

This policy is supported by Durable Medical Equipment Medicare Administrative Contractor (DME MAC) policy.

"Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type" describes a bra with pockets that are intended to hold a mastectomy form or breast prosthesis held adjacent to the chest wall. These do not include an integrated breast prosthesis. They may be constructed of any material (e.g., cotton, polyester or other materials), with any type or location of closure, any size, with or without integrated structural support (e.g., underwire).

"Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type" and "Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type" describe a bra with integrated breast prosthesis, either unilateral or bilateral, respectively. They may be constructed of any material (e.g., cotton, polyester or other materials), with any type or location of closure, any size, with or without integrated structural support (e.g., underwire).

"External breast prosthesis garment, with mastectomy form, post mastectomy" describes a camisole type undergarment with polyester fill used post mastectomy.

A custom fabricated prosthesis is one which is individufally made for a specific patient starting with basic materials. "Custom breast prosthesis, post mastectomy, molded to patient model" describes a molded-to-patient-model custom breast prosthesis. It is a particular type of custom fabricated prosthesis in which an impression is made of the chest wall and this impression is then used to make a positive model of the chest wall. The prosthesis is then molded on this positive model.

Scope of Policy

This Clinical Policy Bulletin addresses external breast prosthesis.

Medical Necessity

Aetna considers external breast prosthesis medically necessary:

  • Following a medically necessary mastectomy;
    • or
  • For persons with gender dysphoria.

    • Aetna considers the following medically necessary:

    Up to four breast prosthesis bras (mastectomy bras):

  • Initially following a medically necessary mastectomy;
    • or
  • For members who have a medically necessary mastectomy form or silicone (or equal) breast prosthesis when the pocket of the bra is used to hold the form/prosthesis;
    • or
  • For members with gender dysphoria;
    • Note

    : Some Aetna plans limit prosthetic coverage to an initial medically necessary prosthesis and do not cover replacement prostheses. Please check benefit plan descriptions for details. Under these plans, an initial external breast prosthesis and up to four initial breast prosthesis bras

    (mastectomy bras) are covered following a medically necessary mastectomy

    or

    for persons with gender dysphoria. For persons who have had a mastectomy, "initial" applies to a breast prosthesis and bras purchased within one year after the mastectomy is performed, not the first breast prosthesis prescribed after the member's Aetna coverage becomes effective.

  • Up to four breast prosthesis bra (mastectomy bra) replacements every 12 months;
  • An external breast prosthesis garment with mastectomy form for:
  • Use in the post-operative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis;
    • or
  • Members with gender dysphoria;
  • Only one breast prosthesis per side for the useful lifetime of the prosthesis;
  • Two breast prostheses, one per side, for:
  • Members who have had bilateral mastectomies;
    • or
  • Members with gender dysphoria;
  • One replacement silicone breast prostheses every 24 months:
  • For fabric, foam, or fiber-filled breast prostheses, replacements are considered medically necessary every 6 months;
  • Replacements of nipple prostheses are considered medically necessary every 3 months;
  • The medical necessity of more frequent replacements must be documented.
    • Note

    : Some Aetna plans limit coverage to an initial breast prosthesis and do not cover replacement prostheses. Please check benefit plan descriptions for details.

    Three gradient compression lymphedema sleeves ("mastectomy sleeves") initially per affected arm, then two replacements every six months.

    Note

    : The Women's Health and Cancer Rights Act (WHCRA) of 1998 (Public Law #105-277) mandates that all insurance companies provide coverage for breast "prostheses and physical complications of mastectomy including lymphedemas."

    Aetna considers the following not medically necessary:

    A breast prosthesis, silicone or equal, with integrated adhesive is considered not medically necessary because it has not been demonstrated to have a clinical advantage over those without the integrated adhesive.

    Note

    : The additional features of a custom-fabricated breast prosthesis, compared to a pre-fabricated silicone breast prosthesis, are not considered medically necessary.

  • More than one external breast prosthesis.