RE: Expansion of Covered Facial Prosthetics under Medicaid Vision Benefit
IMPACTED PLANS: Medicaid, HIV-SNP, and HARP
Dear MetroPlusHealth Provider,
Facial prosthetics are custom-made external devices, typically constructed from medical-grade materials, designed to restore the appearance and/or function of malformed facial anatomy. Effective since April 1, 2026, the New York State Department of Health added the following facial prosthetic procedure codes to the NYS Medicaid Fee- For-Service Vision fee schedule.
These codes are in addition to services related to eye prosthetics that were previously available under the vision benefit. This change has been configured in our system as of the effective date. If applicable, you may need to submit documentation to ensure you will be reimbursed.
| Vision Code | Code Description | Needs Prior Authorization |
|---|---|---|
| L7510 | REPAIR OF PROSTHETIC DEVICE, REPAIR OR REPLACE | NO |
| L7520 | REPAIR PROSTHETIC DEVICE, LABOR COMPONENT | NO |
| L8040 | NASAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN | YES |
| L8041 | MIDFACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN | YES |
| L8042 | ORBITAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN | YES |
| L8043 | UPPER FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN | YES |
| L8044 | HEMI-FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN | YES |
| L8045 | AURICULAR PROSTHESIS, PROVIDED BY A NON-PHYSICIAN | YES |
| L8046 | PARTIAL FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN | YES |
| L8047 | NASAL SEPTAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN | YES |
CPT codes for facial prosthetics may be billed by providers enrolled under the Category of Service (COS) “0405” (Facial/Eye Prosthesis Supplier) who are certified anaplastologists. Anaplastologists design, fabricate, and dispense facial prosthetics (which may include eye prosthetics) and are certified by the Board for Certification in Clinical Anaplastology (BCCA). Providers will be reimbursed for these prosthetics if they are an anaplastologist with an active and valid BCCA certification.
Reimbursements for facial and eye prosthetics will be in accordance with the FFS Vision Fee Schedule, available at emedny.org/ProviderManuals/VisionCare. Please ensure that accurate modifiers are included in each claim submitted.
For certificate submissions and any additional questions, please contact the Provider Relations department at [email protected].