L7405 HCPCS Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS L7405: Upper Extremity Prosthesis Addition for Shoulder Disarticulation, Acrylic

HCPCS Level II code L7405 denotes an addition to an upper extremity prosthesis for patients with shoulder disarticulation or interscapular thoracic amputations made from acrylic material. This code represents a specialized prosthetic component used to adapt or customize high-level upper limb prostheses, reflecting a niche but clinically important segment of prosthetic care focused on complex fittings and patient-specific fabrication. Nationally, accurate coding for such additions affects coverage decisions, billing consistency, and access to appropriate prosthetic customization for beneficiaries.

Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of what L7405 represents clinically and operationally, followed by benchmarking and payer coverage context where available. The publication provides: (1) an overview of the clinical context for shoulder disarticulation/interscapular thoracic prostheses and the role of acrylic additions; (2) typical sites of service and service-line implications for prosthetics and orthotics providers; and (3) summaries of payer coverage patterns and coding considerations relevant to billing and documentation. Data not available in the input is noted where specific payer policies, taxonomies, ICD-10 mappings, related codes, and detailed service-line metrics are required.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareL7405HCPCS Level IIupper extremity prosthesisshoulder disarticulationinterscapular thoracicacrylic prosthetic additionprosthetics and orthoticsoutpatient prosthetic clinic

Billing Code Overview

HCPCS Level II code L7405 describes an addition to an upper extremity prosthesis for shoulder disarticulation/interscapular thoracic amputation levels, constructed of acrylic material. The service type is an upper extremity prosthetic component addition intended to augment or customize a prosthetic socket or structure for high-level shoulder amputations. The typical site of service is an outpatient prosthetics or orthotics clinic or a prosthetic fabrication laboratory equipped to fit and deliver upper extremity prostheses for shoulder disarticulation and interscapular thoracic patients.

Clinical & Coding Specifications

Clinical Context

A 48-year-old male patient with a right shoulder-level amputation (shoulder disarticulation) presents for fitting of a custom prosthetic socket and component additions. The prosthetist evaluates residual limb shape, scapular and thoracic contours, and functional goals (cosmetic restoration, suspension, and stability for transfers). The service involves fabrication and addition of an acrylic material component integrated into an upper extremity prosthesis for a shoulder disarticulation/interscapular thoracic level. Workflow typically includes prosthetic evaluation, cast or digital scan of the torso and residual limb, ordering and fabrication of the acrylic addition in the prosthetics lab, fitting session to adjust fit and suspension, and follow-up visits for adjustments and patient training. Documentation includes the amputation level, sidedness, prior prosthetic history, functional status, measurements/scans, description of the acrylic addition, time and materials used, and any complications or additional services provided.

Coding Specifications

Modifier	Description	When to Use
`LT`	Left side designator (not in provided list)	Data not available in the input.
`11`	Provider or facility billing the usual, customary service (CMS-specific use varies)

HCPCS Level II L7366: Battery Charger, Twelve Volt

HCPCS-L6689-UPPER-EXTREMITY-FRAME-SOCKET-SHOULDER-DISARTICULATION

HCPCS L6689: Upper Extremity Frame-Type Socket, Shoulder Disarticulation

HCPCS-L7260-ELECTRONIC-WRIST-ROTATOR

HCPCS L7260: Electronic Wrist Rotator (Otto Bock or Equal)

HCPCS-L8435-PROSTHETIC-SOCK-UPPER-LIMB

HCPCS L8435: Prosthetic Sock, Multiple Ply, Upper Limb

HCPCS-L5690-LOWER-EXTREMITY-BELOW-KNEE-WAIST-BELT-PADDED-LINED

HCPCS L5690: Addition to Lower Extremity, Below Knee, Waist Belt, Padded and Lined

HCPCS-L8682-IMPLANTABLE-NEUROSTIMULATOR-RADIOFREQUENCY-RECEIVER

HCPCS L8682: Implantable Neurostimulator Radiofrequency Receiver

HCPCS-L5560-PREPARATORY-ABOVE-KNEE-ISCHIAL-SOCKET-PYLON-SACH

HCPCS L5560: Preparatory Above-Knee (Ischial Level) Prosthetic Socket System

HCPCS-L7404-UPPER-EXTREMITY-PROSTHESIS-ABOVE-ELBOW-ACRYLIC-ADDITION

HCPCS L7404: Addition to Upper Extremity Prosthesis, Above Elbow, Acrylic

HCPCS-L5460-ABOVE-KNEE-NON-WEIGHT-BEARING-RIGID-DRESSING-APPLICATION

HCPCS L5460: Above-Knee Non-Weight-Bearing Rigid Post-Surgical Dressing Application

HCPCS-L6905-PARTIAL-HAND-RESTORATION-WITH-GLOVE-MULTIPLE-FINGERS

HCPCS L6905: Hand Restoration, Partial Hand with Glove, Multiple Fingers Remaining

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Taxonomy Code	Specialty	Notes
`218100000X`	Physical Medicine & Rehabilitation (physiatry)	Physiatrists commonly direct prosthetic management and functional goals.
`213E00000X`	Prosthetics & Orthotics	Certified prosthetists perform fabrication, fitting, and adjustments.
`207L00000X`	Orthopedic Surgery	Orthopedic surgeons manage amputations and surgical-level care coordinating prosthetic prescription.
`363A00000X`	Occupational Therapy	Occupational therapists provide training, ADL integration, and functional assessment related to prosthetic use.
`3336C0001X`	Medical Equipment Supplier (DMEPOS)	Suppliers provide durable medical equipment provisioning and billing coordination.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z89.011`	Acquired absence of right shoulder and upper arm	Relevant for right shoulder disarticulation prosthetic additions.
`Z89.012`	Acquired absence of left shoulder and upper arm	Relevant for left shoulder disarticulation prosthetic additions.
`S48.111A`	Complete traumatic amputation of right shoulder at the shoulder level, initial encounter	Trauma-related indication for shoulder disarticulation prosthesis.
`S48.112A`	Complete traumatic amputation of left shoulder at the shoulder level, initial encounter	Trauma-related indication for shoulder disarticulation prosthesis.
`T85.81XA`	Breakdown (mechanical) of prosthetic limb, initial encounter	Used when prosthetic components fail and replacement/addition is needed.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`97530`	Therapeutic activities, direct (one-on-one) patient contact by the provider, each 15 minutes	Used for post-fitting rehabilitation and training in prosthetic use and transfers.
`97750`	Physical performance test or measurement (e.g., musculoskeletal, functional capacity)	Pre- and post-prosthetic functional assessments to document baseline and progress.
`97760`	Orthotic management and training, upper extremity, initial encounter	Training and management related to use of the upper extremity prosthesis after the acrylic addition is fitted.
`99070`	Supplies and materials provided by the physician over and above those usually included with the office visit	Use for non-standard supplies or expendable materials associated with prosthetic adjustment when payer allows.
`96127`	Brief emotional/behavioral assessment (e.g., patient-reported outcomes)	May be used for brief standardized patient outcome measures related to prosthetic acceptance and function.

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