Insurance Reimbursement:

The Jacki is reimbursable through insurance coverage under code L8015.

Here is a brief step-by-step guideline that will help you determine if reimbursement is an option for you.

All plans and plan benefits are different. These steps are not a guarantee of payment, nor are they a guarantee of full payment. We strongly suggest reaching out to your insurance provider for the full details on what they might require, as this is a basic guideline on how to apply for reimbursement.

In the U.S., Medicare sets the general rules for what is or is not covered, and how the benefits apply. Currently Medicare guidelines provide partial reimbursement for the following:

• As many post-surgical garments coded as L8015 as are medically necessary, but not more than 3 per month.

Again, these are Medicare's guidelines, and while this applies to Medicare plans only, the rules are generally the same with private insurers.

Medicare Reimbursement:

Medicare reimburses 80% of the allowable for the Jacki immediately post-surgery, and also an additional Jacki if it is worn as a permanent prosthesis. Reimbursement dollar amounts vary from state to state (for example in Massachusetts in 2020 the amount reimbursed is $58.21). After Medicare pays, secondary insurance carriers are usually required to cover a portion of any remaining cost.

How to obtain a 1490S Medicare Form:

• Download a blank form 1490S and form instructions.
• Go to the Medicare website to download 1490S billing form in PDF format.
• Call 1-800-633-4227 to find the Medicare regional office for your state to order the form by mail.

Make sure you obtain a prescription from your health care provider (Doctor, Nurse Practitioner or Physician Assistant) for "External breast prosthesis garment, with mastectomy form - post mastectomy".

To receive Medicare Reimbursement:

To receive Medicare Reimbursement, please print, complete and mail the following documents to your Medical Regional Office for your state:

1. A prescription from your physician.
2. Complete and sign #1490S Medicare reimbursement billing form. The Medicare description for the Jacki is, "External breast prosthesis garment, with mastectomy form - post mastectomy". You will need to fill out and mail the first 3 pages of this form.
3. The original receipt showing the item purchased and total price.
4. A copy of the ‘Certificate of Medical Necessity’ complete and signed by your physician.
5. Page 12 of the 1490S form shows where you should mail these documents based on your state of residence. You can all call Medicare at 1-800-633-4227 to find the current mailing address for the regional office for your state. Submit the original paperwork to Medicare and always keep a copy of each item for your records.

To obtain reimbursement from Private Insurance:

If you have private insurance, please contact them directly for the exact guidelines and forms necessary to file a claim for reimbursement. Typically you will need:

• your insurer's claim form,
• your prescription,
• a copy of the ‘Certificate of Medical Necessity’ complete and signed by your physician, and
• your receipt for the Jacki purchase.