1. (1) Indications and Coverage:

   1. (a) Covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect;
   2. (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;

   3. (c) The following services and items are included in the allowance for a facial prosthesis:

      1. (A) Evaluation of the client;
      2. (B) Pre-operative planning;
      3. (C) Cost of materials;
      4. (D) Labor involved in the fabrication and fitting of the prosthesis;
      5. (E) Modifications to the prosthesis made at the time of delivery of the prosthesis or within 90 days thereafter;
      6. (F) Repair due to normal wear or tear within 90 days of delivery;
      7. (G) Follow-up visits within 90 days of delivery of the prosthesis;
   4. (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;
   5. (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;
   6. (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;
   7. (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;
   8. (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. (2) Documentation: The following must be submitted for prior authorization (PA):

   1. (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;
   2. (b) A separate prescribing practitioner order is not required for subsequent modifications, repairs or replacement of a facial prosthesis;
   3. (c) A new prescribing practitioner order is required when different supplies are ordered;
   4. (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;
   5. (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;
   6. (f) Requests for replacement, repair or modification of a facial prosthesis must include an explanation of the reason for the service;
   7. (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. (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 for PDF copy.]

Statutory/Other Authority

ORS 413.042 & 414.065

Statutes/Other Implemented

ORS 414.065

History

DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97