L8000 Mastectomy braBreast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type
3 of 3 payer prior-auth lists that name L8000 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Passport by Molina Healthcare (Kentucky), UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | Federal Employee Program (FEP) | AZ | prior auth under conditions | FEP Blue Focus only | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth under conditions | State exception; PA above 5 units per year | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
| UnitedHealthcare Community Plan | Texas STAR+PLUS | TX | prior auth required | Jan 1, 2019 | Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p |
L8000 appears in 6 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Capital Blue Cross.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Cosmetic Surgery and Procedures (0031) | covered if criteria are met (range L8000-L8030) | Jun 25, 2026 | payer document |
| Aetna | External Breast Prosthesis (0097) | covered if criteria are met | Jan 15, 2026 | payer document |
| Aetna | Gender Affirming Surgery (0615) | covered if criteria are met | Sep 8, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Garments (L.1.04.400) | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Prosthetics (L.1.04.401) | covered if criteria are met | payer document | |
| Capital Blue Cross | Reconstructive Breast Surgery Including Management of Breast Implants, External Breast Prosthesis and Post Mastectomy Bras (MP 1.103) Procedure codes | covered if criteria are met | Apr 1, 2026 | payer document |
Prior authorization required or conditional in KY, LA, MA, MS, VA, WV.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.