A mandibular resection prosthesis is indicated when a portion of the mandible is missing or removed due to trauma or ablative surgery. Other prostheses, such as orbital and auricular, may also be needed following this type of surgery and will be covered on the basis of this LCD’s limited coverage. Interim restorative supports such as oral surgical splints and obturator prostheses will be covered within the setting of a comprehensive and documented treatment plan. Maxillary and mandibular prostheses are frequently necessary for the restoration of function, as neither functions in the absence an opposing surface.
Implants, which could be considered dental, but are being inserted to secure, attach or support the maxillofacial prosthesis will be covered when the prosthesis is to be used secondary to maxillofacial surgery or repair of traumatic injury. Use CPT code 21299 to bill the implants with an explanation of the intended use. Please note dates of trauma or tumor biopsy/resection, dates of radiation treatment and other pertinent medical history.
Oral maxillofacial prostheses used in the treatment of obstructive sleep apnea (OSA) will be covered when specifically fashioned to the needs and measurements of individual patients when used to treat essential sleep apnea (780.53) and obstructive sleep apnea (780.57). Use CPT Code 21085 to represent this prosthesis and the work to develop it.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
N/A
Revenue Codes
N/A
CPT/HCPCS Codes
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Note:
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Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
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21076©
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Prepare face/oral prosthesis
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21077©
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Prepare face/oral prosthesis
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21079©
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Prepare face/oral prosthesis
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21080©
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Prepare face/oral prosthesis
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21081©
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Prepare face/oral prosthesis
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21082©
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Prepare face/oral prosthesis
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21083©
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Prepare face/oral prosthesis
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21084©
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Prepare face/oral prosthesis
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21085©*
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Prepare face/oral prosthesis
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*Note: Use this code to bill for oral maxillofacial prostheses for treatment of OSA.
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21086©
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Prepare face/oral prosthesis
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21087©
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Prepare face/oral prosthesis
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21088©
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Prepare face/oral prosthesis
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21089©
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Prepare face/oral prosthesis
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21299©
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Cranio/maxillofacial surgery
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Note: Limited Coverage is not being established for CPT codes 21089 and 21299 at this time.
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 21076, 21077, 21079, 21080, 21081, 21082, 21083, 21084, 21085, 21086, 21087 and 21088:
Covered for:
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140.0–140.1
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Malignant neoplasm of lip
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140.3
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Malignant neoplasm of upper lip, inner aspect
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140.4–140.6
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Malignant neoplasm of lip
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140.8–140.9
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Malignant neoplasm of lip
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141.0–141.3
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Malignant neoplasm of tongue
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141.8
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Other sites of tongue
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142.0–142.2
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Malignant neoplasm of salivary glands
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142.8
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Other major salivary glands
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143.0–143.1
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Malignant neoplasm of gum
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143.8
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Other sites of gum
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144.0–144.1
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Malignant neoplasm of floor of mouth
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144.8
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Other sites of floor of mouth
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145.0–145.6
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Malignant neoplasm of other and unspecified parts of mouth
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145.8
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Other specified parts of mouth
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146.0–146.8
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Malignant neoplasm of oropharnyx
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147.0–147.3
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Malignant neoplasm of nasopharynx
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147.8
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Other specified sites of nasopharynx
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148.0–148.3
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Malignant neoplasm of hypopharynx
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148.8
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Other specified sites of hypopharynx
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149.0–149.1
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Malignant neoplasm of other and ill-defined sites within the lip, oral cavity and pharynx
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149.8
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Other- malignant neoplasms of lip, oral cavity, and pharynx whose point of origin cannot be assigned
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160.0–160.5
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Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
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160.8–160.9
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Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
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161.0–161.3
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Malignant neoplasm of larynx
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161.8–161.9
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Malignant neoplasm of larynx
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170.0–170.1
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Malignant neoplasm of bone and articular cartilage
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171.0
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Malignant neoplasm of connective and other soft tissue of head, face and neck
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172.0–172.1
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Malignant melanoma of skin
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172.3–172.4
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Malignant melanoma of skin
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172.8
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Other unspecified sites of skin
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190.1–190.2
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Malignant neoplasm of eye
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190.7
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Malignant neoplasm of eye, lacrimal duct
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200.31
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Marginal zone lymphoma, lymph nodes of head, face, and neck
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200.41
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Mantle cell lymphoma, lymph nodes of head, face, and neck
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200.51
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Primary central nervous system lymphoma, lymph nodes of head, face, and neck
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200.61
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Anaplastic large cell lymphoma, lymph nodes of head, face, and neck
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200.71
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Large cell lymphoma, lymph nodes of head, face, and neck
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202.71
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Peripheral T cell lymphoma, lymph nodes of head, face, and neck
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210.1–210.9
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Benign neoplasm of lip, oral cavity, and pharynx
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212.0
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Benign neoplasm of nasal cavities, middle ear and accessory sinuses
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216.0
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Benign neoplasm of skin of lip
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224.1
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Benign neoplasm of orbit
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234.0
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Globe of eye, Carcinoma in situ
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237.70–237.73
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Neurofibromatosis
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237.79
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Other neurofibromatosis
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237.9
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Neoplasm of uncertain behavior of other and unspecified parts of nervous system
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360.89
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Other disorders of the globe, acquired anopthalmos
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376.03
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Osteomyelitis of orbit
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376.13
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Parasitic infection of orbit
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376.40
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Deformity of orbit
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376.6
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Penetrating wound of orbit
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446.3–446.4
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Polyarteritis nodosa and allied conditions
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519.09
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Fistula due to tracheostomy
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526.0–526.5
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Diseases of the jaws
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526.81
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Exostosis of jaw
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526.89
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Other specified diseases of the jaws
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526.9
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Unspecified diseases of the jaws
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733.45
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Aseptic necrosis of bone, jaw
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733.90–733.91
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Other and unspecified disorders of bone and cartilage
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787.20-787.22
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Dysphagia
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870.0–870.4
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Open wound of ocular adnexa
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870.8–870.9
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Open wound of ocular adnexa
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871.0–871.7
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Open wound of eyeball
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871.9
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Unspecified open wound of eyeball
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872.00–872.12
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Open wound of ear
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872.61–872.64
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Other specified parts of ear, without mention of complication
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872.69
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Open wound of other and multiple sites of ear, uncomplicated
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872.71–872.74
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Other specified parts of ear, complicated
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872.79
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Open wound of other and multiple sites of ear, complicated
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872.8–872.9
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Open wound of ear
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873.0–873.1
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Other open wound of head
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873.20–873.23
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Open wound of nose, without mention of complication
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873.29
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Open wound of multiple sites, uncomplicated
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873.30–873.33
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Open wound of nose, complicated
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873.39
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Open wound of multiple sites of nose, complicated
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873.40–873.44
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Open wound of face, without mention of complication
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873.49
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Open wound of other and multiple sites of face, uncomplicated
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873.50–873.54
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Open wound of face complicated
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873.59
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Open wound of other and multiple sites of face, complicated
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873.60–873.65
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Open wound of internal structures of mouth, without mention of complication
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873.69
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Open wound of other and multiple sites of mouth, uncomplicated
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873.70–873.75
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Open wound of internal structures of mouth, complicated
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873.79
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Open wound of other and multiple sites of mouth, complicated
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873.8–873.9
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Other open wound of head
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Medicare is establishing the following limited coverage for CPT code 21085 (when used to represent prosthesis for treatment of OSA):
Covered for:
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327.20–327.27
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Organic sleep apnea
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327.29
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Other organic sleep apnea
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780.53
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Hypersomnia with sleep apnea
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780.57
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Other and unspecified sleep apnea
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Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.