Schedule 5 - Appendix A - Surgically Implanted Prostheses

PLASTIC AND RECONSTRUCTIVE
Billing Code Product Further Size Notations
MN019 Siltex High Profile Gel-filled Mammary Prostheses 125cc-Model 354-4125; In strict accordance with
Mammary Prostheses 150cc-Model 354-4150; the requirements of the
175cc-Model 354-4175; Medicare Benefits
200cc-Model 354-4200; Schedule Items Number
225cc-Model 354-4225; 45524, 45527, 45528,
250cc-Model 354-4250; 45542, 45552, 45554,
275cc-Model 354-4275; 45555 only.
300cc-Model 354-4300;
325cc-Model 354-4325;
350cc-Model 354-4350;
375cc-Model 354-4375;
400cc-Model 354-4400;
425cc-Model 354-4425;
450cc-Model 354-4450;
500cc-Model 354-4500;
Prostheses, Mammary, Internal, Gel-Filled
MN013 Mentor Siltex Becker 150, 200, 250, 300, 350, 400, 500, In strict accordance with
Expander/Mammary Prostheses 600, 700. 800cc the requirements of the
Medicare Benefits
Schedule Items Number
45524, 45527, 45528,
45542, 45552, 45554,
45555 only.
MN014 Mentor Medical Systems Smooth Low 100,125,150,175,200,225,250,275, In strict accordance with
Bleed Gel-Filled, Mammary 300,325,400,450,500,550,600,700, the requirements of the
Prostheses Breast, Permanently 800cc Medicare Benefits
Schedule Items Number
45524, 45527, 45528,
45542, 45552, 45554,
45555 only.
MN015 Mentor Siltex Low Bleed Gel-Filled 100,125,150,175,200,225,250,275, In strict accordance with
(Moderate Profile) Mammary 300,325,350,375,400,500,550,600, the requirements of the
Prostheses Breast, Permanently 700,800cc Medicare Benefits
Schedule Items Number
45524, 45527, 45528,
45542, 45552, 45554,
45555 only.
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