Aetna Commercial Clinical Policy

Aetna Facial Prostheses, External Form

Effective Date

06/18/2002

Last Reviewed

09/12/2023

Original Document

  Reference



Background for this Policy

This policy is based upon Medicare DME MAC policy.

An external nasal prosthesis is a removable superficial prosthesis that restores all or part of the nose. It may include the nasal septum.

An external mid-facial prosthesis is a removable superficial prosthesis that restores part or all of the nose plus significant adjacent facial tissue/structures, but does not include the orbit or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek, upper lip, or forehead.

An external orbital prosthesis is a removable superficial prosthesis that restores the eyelids and the hard and soft tissue of the orbit. It may also include the eyebrow. An orbital prosthesis may or may not include the ocular prosthesis component.

An external upper facial prosthesis is a removable superficial prosthesis that restores the orbit plus significant adjacent facial tissue/structures, but does not include the nose or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek or forehead.

An external hemi-facial prosthesis is a removable superficial prosthesis that restores part or all of the nose plus the orbit plus significant adjacent facial tissue/structures, but does not include any intraoral maxillary component.

An external auricular prosthesis is a removable superficial prosthesis that restores all or part of the ear.

A superficial partial facial prosthesis is a removable superficial prosthesis that restores a portion of the face but which does not specifically involve the nose, orbit or ear.

An external nasal septal prosthesis is a removable prosthesis that occludes a hole in the nasal septum but does not include superficial nasal tissue.

Appendix

Note

: The following services and items are included in the allowance for a facial prosthesis and, therefore, are not separately reimbursed:

  • Evaluation of the member
  • Pre-operative planning
  • Cost of materials
  • Labor involved in the fabrication and fitting of the prosthesis
  • Modifications to the prosthesis made at the time delivery of the prosthesis or within 90 days thereafter
  • Repair due to normal wear or tear within 90 days of delivery
  • Follow-up visits within 90 days of delivery of the prosthesis.

    • Modifications to a prosthesis are separately payable when they occur more than 90 days after delivery of the prosthesis and they are medically necessary because of a change in the member’s condition.

    Scope of Policy

    This Clinical Policy Bulletin addresses facial prostheses, external.

    Medical Necessity

    Aetna considers superficial facial prosthesis and associated supplies medically necessary as per below:

  • Superficial facial prosthesis when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect, regardless of whether the facial prosthesis restores function. See
    • CPB 0031 - Cosmetic Surgery and Procedures
  • ;
  • Adhesives, adhesive remover, and tape used in conjunction with a facial prosthesis.

    • Policy Limitations and Exclusions

    Note: Other skin care products related to the prosthesis, including but not limited to cosmetics, skin cream, cleansers, etc., are not covered as they are not considered medical items.