OAR 410-122-0680
Facial Prostheses


(1)

Indications and Coverage:

(a)

Covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect;

(b)

Adhesives, adhesive remover and tape used in conjunction with a facial prosthesis are covered. Other skin care products related to the prosthesis, including but not limited to cosmetics, skin cream, cleansers, etc., are not covered;

(c)

The following services and items are included in the allowance for a facial prosthesis:

(A)

Evaluation of the client;

(B)

Pre-operative planning;

(C)

Cost of materials;

(D)

Labor involved in the fabrication and fitting of the prosthesis;

(E)

Modifications to the prosthesis made at the time of delivery of the prosthesis or within 90 days thereafter;

(F)

Repair due to normal wear or tear within 90 days of delivery;

(G)

Follow-up visits within 90 days of delivery of the prosthesis;

(d)

Modifications to a prosthesis that occur more than 90 days after delivery of the prosthesis and that are required because of a change in the client’s condition are covered;

(e)

Repairs are covered when there has been accidental damage or extensive wear to the prosthesis that can be repaired. If the expense for repairs exceeds the estimated expense for a replacement prosthesis, no payments can be made for the amount of the excess;

(f)

Follow-up visits which occur more than 90 days after delivery and which do not involve modification or repair of the prosthesis are non-covered services;

(g)

Replacement of a facial prosthesis is covered in cases of loss or irreparable damage or wear or when required because of a change in the client’s condition that cannot be accommodated by modification of the existing prosthesis;

(h)

When a prosthesis is needed for adjacent facial regions, a single code must be used to bill for the item, whenever possible. For example, if a defect involves the nose and orbit, this should be billed using the hemi-facial prosthesis code and not separate codes for the orbit and nose. This would apply even if the prosthesis is fabricated in two separate parts.

(2)

Documentation: The following must be submitted for prior authorization (PA):

(a)

An order for the initial prosthesis and/or related supplies which is signed and dated by the ordering prescribing practitioner must be kept on file by the prosthetist/supplier and submitted with request for PA;

(b)

A separate prescribing practitioner order is not required for subsequent modifications, repairs or replacement of a facial prosthesis;

(c)

A new prescribing practitioner order is required when different supplies are ordered;

(d)

A photograph of the prosthesis and a photograph of the client without the prosthesis must be retained in the supplier’s record and must be submitted with the PA request;

(e)

When code L8048 is used for a miscellaneous prosthesis or prosthetic component, the authorization request must be accompanied by a clear description and a drawing/copy of photograph of the item provided and the medical appropriateness;

(f)

Requests for replacement, repair or modification of a facial prosthesis must include an explanation of the reason for the service;

(g)

When replacement involves a new impression/moulage rather than use of a previous master model, the reason for the new impression/moulage must be clearly documented in the authorization request.

(3)

Procedure Codes — Table 122-0680.
[ED. NOTE: Tables referenced are available from the agency.]
[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]
410‑122‑0010
Definitions
410‑122‑0020
Orders
410‑122‑0040
Prior Authorization
410‑122‑0080
Conditions of Coverage, Limitations, and Restrictions
410‑122‑0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients)
410‑122‑0180
Healthcare Common Procedure Coding System Level II Coding
410‑122‑0182
Legend
410‑122‑0184
Repairs, Servicing, Replacement, Delivery, and Dispensing
410‑122‑0186
Payment Methodology
410‑122‑0188
DMEPOS Rebate Agreements
410‑122‑0200
Pulse Oximeter for Home Use
410‑122‑0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea
410‑122‑0203
Oxygen and Oxygen Equipment
410‑122‑0204
Nebulizer
410‑122‑0205
Respiratory Assist Devices
410‑122‑0206
Intermittent Positive Pressure Breathing
410‑122‑0207
Respiratory Supplies
410‑122‑0208
Suction Pumps
410‑122‑0209
Tracheostomy Care Supplies
410‑122‑0210
Ventilators
410‑122‑0211
Cough Stimulating Device
410‑122‑0220
Pacemaker Monitor
410‑122‑0240
Apnea Monitors for Infants
410‑122‑0250
Breast Pumps
410‑122‑0260
Home Uterine Monitoring
410‑122‑0280
Heating/Cooling Accessories
410‑122‑0300
Light Therapy
410‑122‑0320
Manual Wheelchair Base
410‑122‑0325
Power Wheelchair Base
410‑122‑0330
Power-Operated Vehicle
410‑122‑0340
Wheelchair Options/Accessories
410‑122‑0360
Canes and Crutches
410‑122‑0365
Standing and Positioning Aids
410‑122‑0375
Walkers
410‑122‑0380
Hospital Beds
410‑122‑0400
Pressure Reducing Support Surfaces
410‑122‑0420
Hospital Bed Accessories
410‑122‑0475
Therapeutic Shoes for Diabetics
410‑122‑0510
Osteogenesis Stimulator
410‑122‑0515
Neuromuscular Electrical Stimulator (NMES)
410‑122‑0520
Glucose Monitors and Diabetic Supplies
410‑122‑0525
External Insulin Infusion Pump
410‑122‑0540
Ostomy Supplies
410‑122‑0560
Urological Supplies
410‑122‑0580
Bath Supplies
410‑122‑0590
Patient Lifts
410‑122‑0600
Toilet Supplies
410‑122‑0620
Miscellaneous Supplies
410‑122‑0625
Surgical Dressing
410‑122‑0630
Incontinent Supplies
410‑122‑0640
Eye Prostheses
410‑122‑0655
External Breast Prostheses
410‑122‑0658
Gradient Compression Stockings/Sleeves
410‑122‑0660
Orthotics and Prosthetics
410‑122‑0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses
410‑122‑0678
Dynamic Adjustable Extension/Flexion Device
410‑122‑0680
Facial Prostheses
410‑122‑0700
Negative Pressure Wound Therapy Pumps
410‑122‑0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0680’s source at or​.us