Schedule 5 - Appendix A - Surgically Implanted Prostheses

PLASTIC AND RECONSTRUCTIVE
Billing Code Product Further Size Notations
BI569 TMJ System Fossa Component, Left or Right; Small, Medium Large Only to be funded where
Titanium, UHMWPE used in a service for
which a Medicare Benefit
is payable
BI570 TMJ System Screw, Cross Drive, Fossa; Titanium (2.0 or 2.3) x (5 - 13) mm Only to be funded where
used in a service for
which a Medicare Benefit
is payable
Prostheses, Joint, Mandibular Condyle
BI742 TMJ System Screw, Cross Drive Emergency, 3.2 mm (dia) x 8, 10, 12mm (lengths) Only to be funded where
Mandibular Component, Titanium used in a service for
which a Medicare Benefit
is payable
BI745 TMJ System Screw, Cross Drive, Mandibular 2.7 mm (dia) x 8, 10, 12mm (lengths) Only to be funded where
Component, Titanium used in a service for
which a Medicare Benefit
is payable
Screws
BI397 Lactosorb Resorbable Bone Screw, Lactosorb 1.5mm, 2mm (1.5, 2.0, 2.5, 2.8) x (3 - 17mm) Only to be funded where
Craniomaxillofacial Fixation System system; pkt 2, PGA/PLA used in a service for
which a Medicare Benefit
is payable
BI399 Lactosorb Resorbable Cover, solid. Lactosorb PGA/PLA (0.25, 0.5, 0.75mm) x 25x25mm Only to be funded where
Craniomaxillofacial Fixation System used in a service for
which a Medicare Benefit
is payable
BI400 Lactosorb Resorbable Cover, Solid Lactosorb PGA/PLA (0.25, 0.5, 0.75mm) x 38x38mm Only to be funded where
Craniomaxillofacial Fixation System used in a service for
which a Medicare Benefit
is payable
BI401 Lactosorb Resorbable Cover, Solid Lactosorb PGA/PLA (0.25, 0.5, 0.75mm) x 50x50mm Only to be funded where
Craniomaxillofacial Fixation System used in a service for
which a Medicare Benefit
is payable
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