Does S8950 require prior authorization?

No, S8950 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for S8950?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`S8950`, Complex lymphedema therapy, each 15 minutes

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; medical records documentation used for reviews (general statement from policy).
Documentation of prior Mastectomy (operative report, pathology report, or other clinical record) to support reconstruction related to Mastectomy and WHCRA entitlement.

Clinical documentation supporting diagnosis when reconstruction is for congenital disorders or severe breast disfigurement (e.g., diagnosis of Poland syndrome, Turner syndrome, amastia, radiation-related disfigurement).

When requesting correction of inverted nipples, documentation of either: a documented history of chronic nipple discharge, bleeding, scabbing, or ductal infection; OR evidence that the inverted nipple is the result of a congenital anomaly.

For treatment of lymphedema and related services, documentation of lymphedema diagnosis (e.g., I97.2 Postmastectomy lymphedema syndrome) and records supporting prescribed therapy (e.g., orders/therapy notes for complex decongestive physiotherapy, DME orders for lymphedema pumps, prescriptions/fit notes for compression sleeves, documentation of elastic bandages/wraps associated with medical treatment).

For implant removal related to Allergan BIOCELL textured breast implants, documentation of the implanted device brand/type demonstrating Allergan BIOCELL textured implant exposure/implant history.

Key Coverage Criteria

Treatment for post-mastectomy complications including postoperative infection(s).
Breast reconstruction after Mastectomy with or without a diagnosis of cancer in accordance with the Women's Health and Cancer Rights Act of 1998 (reconstruction of the breast on which the Mastectomy was performed).
Surgery and reconstruction of the contralateral breast to produce a symmetrical appearance, including nipple tattooing (per WHCRA).
Prostheses (implanted and/or external) related to breast reconstruction post-mastectomy (per WHCRA).
Treatment of physical complications of Mastectomy, including lymphedema (including complex decongestive physiotherapy (CDP), lymphedema pumps [considered durable medical equipment], compression lymphedema sleeves [considered a prosthetic device], elastic bandages and wraps associated with medically necessary treatments for complications of lymphedema).
Breast reconstruction during or post Mastectomy and reconstruction for treatment of congenital disorder (e.g., Poland syndrome, Turner syndrome) or severe breast disfigurement (e.g., amastia, radiation) when considered reconstructive and medically necessary in accordance with InterQual CP: Procedures, Breast Reconstruction.

5 Active Policies

CARELON-physical-therapy-occupational-therapy-and-speech-therapy-2024-04-14, Physical Therapy Occupational Therapy and Speech Therapy

UHC-POL-breast-reconstruction, Breast Reconstruction

CIGNA-CPG157, Complex Lymphedema Therapy (Complete Decongestive Therapy)

UMR-POL-UMR-breast-reconstruction, Breast Reconstruction

SUREST-POL-SUREST-breast-reconstruction, Breast Reconstruction

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S8950, Complex lymphedema therapy, each 15 minutes