17.3.3 Breast Prosthesis

The following procedure codes for external breast prostheses are benefits of the CSHCN Services Program when provided by a licensed prosthetist or licensed orthotist to clients with a history of a medically necessary mastectomy procedure:

Procedure Code	Limitations
L8000	4 per rolling year, same procedure, any provider
L8001	4 per rolling year, same procedure, any provider Modifier LT or RT required.
L8002	4 per rolling year, same procedure, any provider
L8010	8 per rolling year, same procedure, any provider
L8015	2 per lifetime, any provider regardless of modifier
L8020	1 per 6 rolling months, same procedure, any provider
L8030	1 per 2 rolling years, same procedure, any provider
L8031	1 per 2 rolling years, same procedure, any provider Modifier LT or RT required.
L8032	8 per rolling year, same procedure, any provider
L8035	Requires prior authorization
L8039	Requires prior authorization

Refer to:

Section 31.2.36.12, “Mastectomy and Related Services,” on page 31‑118, for information about mastectomy procedures and related services.