Dear Customers,

 

FeelingWholeAgain.com (Custom DME, LLC) does not bill your healthcare insurer for you. Below are a few reasons why and a few things you should know.

 

Healthcare costs are increasing in the United States at an alarming rate and we believe that one of the solutions is price transparency, which is why we list the price of our services on our website. We also believe that contracts between insurers and healthcare providers do not benefit patients. We do our best to provide a valuable service at a low price. Our customers come from across the country and around the world. In order to keep our prices low, we do not bill insurance because it does not greatly benefit the majority. We would spend too much time working with insurance companies and this cost would get passed on to you, our customers. Furthermore, most of our customers would have to pay the full amount anyway because the deductible needs to be paid before insurance will cover anything. Although it depends on the plan you purchased, most likely your prostheses will be covered. The question is "how much will they pay?". Government insurance plans (such as Medicaid and Medicare) will only pay about $35 for code L8032 for a mass-produced nipple prosthesis that will last three months. If you have a premium plan, the majority of the cost may be covered. If you feel it is worth the effort, and would like to submit a claim to your insurance company for your prostheses, you should:

 

  • Call Customer Service of your insurer and tell them that you would like nipple prostheses.
  • There are two billing codes for nipple prostheses. Code L8032 (HCPCS procedure code for: Nipple Prosthesis, reusable, any type, each, code became effective on 1/1/2010 and is used for mass-produced nipple prosthetics that last only three months). Code L8039 (breast prosthesis, not specified) is the code that should be used for custom made nipple prostheses. Our nipple prostheses are different because they are custom made and are a much better value. We believe that once insurance companies see this, they will reimbuse you at the full amount. Not only will they fit your breast(s), they come with a two year warranty and a 90 day satisfaction guarantee. Our prostheses cannot be readily purchased. Our prostheses are not retail products. - wee provide them as a service. Ultimately, you want your insurance company to understand that this is by far the best value and best product. 
  • If they ask for a letter of medical necessity, you can use the template at the bottom of this page. If you need to submit documentation, you should also submit a note from your doctor that says these custom prostheses will serve you best.
  • You should obtain an authorization number if possible. If they do not give you an authorization number, you can ask for a reference number. 
  • Ask to be directed to a member claim form so that you can be reimbursed. When you submit the claim, you will need to send in a copy of your receipt. You may want to send a medical necessity letter or a prescription note (with your full name, date of birth, and diagnosis) from your doctor for nipple prosthetics. Show the cost of EACH prosthesis. You can also submit the medical adhesive to insurance. If you would like to submit a claim to your insurance for medical adhesive for an external breast prosthesis, the code is A6534 with an AV modifier for 1 oz. of liquid adhesive. The AV modifier tells the insurance company that the adhesive is for the prosthetic device. You will need to include the following codes in the claim form:
    • PROCEDURE CODES: The proper procedural code is L8039. The reason it is not L8032 is because we offer a service, not a retail product. We have used L8032 for several years and we learned that the insurance companies pay for the prostheses but only up to their allowable amount for that code (remember that it is intended for mass-produced nipple prostheses that only last three months). You should list this twice. Use an LT modifier to indicate that it is for the left breast. Use an RT modifier to indicate that the other code is for the right breast.
    • DIAGNOSIS CODES: Additionally, you will need to include the reason for the acquired absence of your breast(s) and nipple(s) by including two codes. 
      • First, choose one of these:
        • Z90.10 Acquired absence of unspecified breast and nipple
        • Z90.11 Acquired absence of right breast and nipple
        • Z90.12 Acquired absence of left breast and nipple
        • Z90.13 Acquired absence of bilateral breasts and nipples
      • Then choose one of these:
        • Z85.3 Personal history of malignant neoplasm of breast
        • C50.011 Malignant neoplasm of nipple and areola, right female breast
        • C50.012 Malignant neoplasm of nipple and areola, left female breast
        • C50.019 Malignant neoplasm of nipple and areola, unspecified female breast
        • C50.919 Malignant neoplasm of unspecified site of unspecified female breast
        • D05.90 Unspecified type of carcinoma in situ of unspecified breast (male)
        • D05.91 Unspecified type of carcinoma in situ of right breast (male)
        • D05.92 Unspecified type of carcinoma in situ of left breast (male)
  • After you receive your prostheses and detailed receipt, you can submit your claim form and the supporting documentation. It could take as long as a few months to get reimbursed. 

 

Here are a few tips while working with your insurer:

 

  • Always take as many notes as you can. Write down names and titles of those you talk to, get direct phone numbers, and always ask for some sort of documentation or a reference number. Keep track of how much time you spend working with them. If you send them a letter or form, be sure to make a copy of it so that you know what you submitted. If they claim they did not receive it, send it again using USPS certified mail.
  • If your insurer will not cover nipple prostheses as a part of breast reconstruction, kindly ask them to specify where it states that in your policy’s documentation. If no policy exists, do not be afraid to ask for a superior.
  • Always be kind. There is no need to get upset. These are people on the other side of the telephone line and they are usually quite nice. They have no ill intention and are doing the job they are paid to do. Being kind and courteous will benefit you much more than being rude and demanding. When a representative from your insurance company gets to know you, they will be much more helpful.
  • Health insurers have 4 levels of appeals. If you feel like it really should be covered based on your plan description and you were denied coverage, you can always appeal their decision. We suggest sending in a letter stating why you believe it is necessary that they cover the cost of the prostheses and why you believe a prosthesis is better than surgery in your situation. Insurance companies are very focused on the cost versus benefit for both the prostheses and surgery. Photographs of the prostheses may help your case. You may also use the Women’s Health and Cancer Rights Act in your argument (http://www.cancer.org/docroot/mit/content/mit_3_2x.asp). Keep your cool and be friendly and as direct as possible.
  • You are their customer and they need your business to be successful. Just like you, they want to keep their costs down. By choosing nipple prostheses, you are selecting the cost effective option. They should also be happy that you chose Custom DME because of our costs.
  • If you have an issue with reimbursement, you can kindly remind them that we provide this service at a much better value that the generic prosthesis that is covered at $35 by the government and lasts only 3 months. We offer a 90 day satisfaction guarantee and the prostheses are under a no charge repair/replace warranty for 2 years - which means that they will last more than 2 years. If it costs 6.28 times more than the mass produced prosthesis, but lasts at least 8 times longer, it is a much better value and you are saving them money by purchasing the more expensive prosthesis but replacing it far less often. This is just the cost argument! You can also explain how the prosthesis is custom made to you breast shape, looks  just like your areola/nipple, and functions far better (such as staying glued on for two weeks at a time during ANY activity)! The benefits far outweigh the costs and your insurance company would be short sighted to not see the benefit at the additional expense if they truly look into it. You may need to appeal your claim reimbursement amount. 

 

We are a manufacturing company and your local mastectomy supply store could potentially submit an order and an insurance claim for you. They usually offer the service of billing your insurance provider but your insurance carrier will be charged more by the supply store for the billing services. If you purchase a premium health insurance plan, it may be more cost effective to order our prostheses through a local store that has an "in-network" contract with your insurer, than to purchase directly from this website.

 

Thank you for considering our prostheses,

 

Paul Tanner, CCA

Owner & Designer

Custom DME, LLC