Schedule 5 - Appendix A - Surgically Implanted Prostheses

PLASTIC AND RECONSTRUCTIVE
Billing Code Product Further Size Notations
MN016 Mentor Siltex Low Bleed Gel-Filled 75, 200, 225, 250, 275, 300, 325, In strict accordance with
(High Profile) Mammary Prostheses 350, 400, 450, 500, 550cc the requirements of the
Breast, Permanently Implantable Medicare Benefits
Schedule Items Number
45524, 45527, 45528,
45542, 45552, 45554,
45555 only.
MN017 Mentor Medical Systems Contour 120,135,155,180,215,245,280,315, In strict accordance with
Profile Gel-filled Mammary 355,395,440,480,530,640,775cc the requirements of the
Prostheses, Breast, Permanently Medicare Benefits
Schedule Items Number
45524, 45527, 45528,
45542, 45552, 45554,
45555 only.
Prostheses, Mammary, Internal, Inflatable
MN004 Mentor Siltex Spectrum Saline Tissue Saline Mammary Prostheses Volume 275cc - 650cc In strict accordance with
Expander the requirements of the
Medicare Benefits
Schedule Items Number
45524, 45527, 45528,
45542, 45552, 45554,
45555 only.
MN010 Mentor Saline-Filled Anterior Mammary Prothesis - Smooth 125 to 700cc In strict accordance with
Diaphragm Valve Mammary Prosthesis the requirements of the
Medicare Benefits
Schedule Items Number
45524, 45527, 45528,
45542, 45552, 45554,
45555 only.
MN011 Mentor Saline Siltex Anterior Mammary Prothesis - Textured 125 to 475cc In strict accordance with
Diaphragm ValveMammary Prosthesis the requirements of the
Medicare Benefits
Schedule Items Number
45524, 45527, 45528,
45542, 45552, 45554,
45555 only.
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