CurrentCapital BluecrossPolicy MP 6.052

Upper Limb Prostheses

Defines medical necessity, investigational uses, coding, and coverage rules for upper-limb prostheses (passive, preparatory, body-powered, myoelectric/electric), associated sockets, components, accessories, adjustments, repairs, and replacements for Capital Blue Cross products (policy MP 6.052).

Policy Summary

PayerCapital Bluecross

PolicyUpper Limb Prostheses

Policy CodePolicy MP 6.052

Change TypeAdministrative updates; coding additions/removals

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionA certified prosthetist must determine and document that the selected prosthesis is appropriate to meet the member's functional needs.

SourceLink

POLICY UPDATE CHANGES

03/16/2026 Administrative update removed codes L6010 and L6020 effective 04/01/2026.

03/12/2025 Administrative Update added codes L6028-L6033, L6037, L6700, L7406 effective 04/01/2025.

06/01/2022 Procedure code L7499 added to policy.

Multiple consensus reviews (2020-2025) stated policy intent/statement unchanged; references and coding table formatting updated.

3Prosthesis categories addressed

~5 yrsTypical prosthesis lifespan

MultipleHCPCS L-codes listed

Coverage Summary

Scope: Defines medical necessity, investigational uses, coding, and coverage rules for upper-limb prostheses (passive, preparatory, body-powered, myoelectric/electric), associated sockets, components, accessories, adjustments, repairs, and replacements for Capital Blue Cross products under policy MP 6.052. Coverage stance: mixed (combination of medically necessary and investigational statements). Effective date: 2026-04-01. Last review: 2026-03-16.

Key facts: upper-limb prostheses

Prosthesis categories addressed3

Typical prosthesis lifespan~5 years (life of a prosthesis is approximately 5-years)

Codes listed (HCPCS L-codes)Multiple (extensive list of L-codes included in Coding Information and Covered when medically necessary sections)

Medical Necessity Criteria

Preparatory Prosthesis

Covered/Investigational statements for preparatory prosthesis

ANY of the following

A preparatory prosthesis may be considered medically necessary after surgery to prevent edema of the residual limb.
Additions are investigational for preparatory prosthesis since these have all initial components.
All other uses of preparatory prosthesis are considered investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Passive Functional Prosthesis

Coverage conditions for passive functional prosthesis

ALL of the following

Passive functional prosthesis does not include any mechanical working parts; relies on manual repositioning and cannot restore function.
A passive functional prosthesis may be considered medically necessary only when there is clear documentation that the requested prosthesis is required to perform activities of daily living (ADLs).
All other uses of passive functional prosthesis are considered investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Body-Powered Prostheses

Criteria for medical necessity of body-powered upper extremity prostheses

ALL of the following

The member has history of upper limb amputation or absence of upper limb(s).
A certified prosthetist determines a body-powered upper extremity prosthesis is appropriate to meet the member's functional needs.
Socket and suspension system rules: No more than two test (diagnostic) sockets may be considered medically necessary for an individual prosthesis without additional documentation of medical necessity.
Socket inserts: No more than two of the same socket inserts are allowed at the same time.

Electric/Myoelectric Prostheses

Criteria for medical necessity of electric and myoelectric upper limb prosthetic components

ALL of the following

The individual has an amputation or missing limb at the wrist or above (forearm, elbow, etc.).
Standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of the individual in performing ADLs.
The remaining musculature of the arm(s) contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device.
The individual has demonstrated neurological and cognitive function to operate the prosthesis effectively.
The individual is free of co-morbidities that could interfere with function of the prosthesis (neuromuscular disease, etc.).

Additions, Adjustments, Repairs, Replacement

Coverage statements for accessory and maintenance services

ALL of the following

Accessories (sheaths, socks, hinges, switches, extensions, adaptors, cables, etc.) may be considered medically necessary when these appliances aid in or are essential to the effective use of the prosthetic limb.
Billing timing: Additions should be billed on the same claim as the base procedure when supplied at the same time as the base procedure.
Adjustments/modifications: Adjustments and/or modifications to the prosthesis required by wear and tear or due to a change in individual's condition (such as growth in a child) or to improve the function may be considered medically necessary.
Repairs necessary to make the prosthetic functional may be considered medically necessary; expense for repairs may not exceed the estimated expense of purchasing another prosthesis.

Coding

Covered when medically necessary - listed L-codesHCPCSCovered

L6000
L6028
L6029
L6030
L6031
L6032
L6033
L6037
L6050
L6055

1–10 of 152

1/16

Investigational / Not covered (insufficient evidence)HCPCSExperimental

L6034	Listed as investigational in one section and also in covered list; policy text also lists L6034-L6039 as investigational in Procedure Codes section.
L6036	Investigational; insufficient evidence.
L6038	Investigational; insufficient evidence.
L6039	Investigational; insufficient evidence.
L6026	Investigational; insufficient evidence.
L6715	Investigational; insufficient evidence.
L6880	Investigational; insufficient evidence.

Provider Actions

Documentation Required

Certified prosthetist determination

A certified prosthetist must determine and document that the selected prosthesis is appropriate to meet the member's functional needs.

Documentation Required

Functional documentation for passive prosthesis

Clear documentation that the requested passive functional prosthesis is required to perform activities of daily living (ADLs) is required for medical necessity.

Billing Rule

Socket/test socket limits

No more than two test (diagnostic) sockets may be considered medically necessary for an individual prosthesis without additional documentation. No more than two of the same socket inserts are allowed at the same time.

Examples: limits apply to diagnostic/test sockets and identical socket inserts supplied concurrently.

Billing Rule

Additions billed with base procedure

Additions should be billed on the same claim as the base procedure when supplied at the same time as the base procedure.

Documentation Required

Socket/sock replacement justification

Socket and socket insert replacements require documentation of functional and/or physiological need (examples include changes in the residual limb, functional need changes, irreparable damage due to wear and tear, wear and tear due to excessive weight, and prosthetic demands of a very active amputee).

Documentation Required

Replacement timing

Replacement prosthesis may be considered medically necessary only if the previous prosthesis is no longer functional. The policy notes the typical life of a prosthesis is approximately 5 years.

Background & Evidence

Background: Upper-limb prostheses aim to restore function and natural appearance while providing comfort for continued acceptance. Prostheses are classified into three categories: passive (no mechanical working parts, lightest and most comfortable but cannot restore function), body-powered (harness and cable-driven systems that provide functional manipulation but may cause harness discomfort and have aesthetic limitations), and myoelectric (battery-powered, driven by electromyographic signals to operate motors; can offer more natural control and appearance but are heavier, costlier, and require maintenance).

Advantages/disadvantages: Passive prostheses are light and comfortable but nonfunctional; body-powered devices offer reliable mechanical control and grip strength but can be uncomfortable and less cosmetically pleasing; myoelectric systems can provide improved appearance and physiologic control for some tasks but may have weight, cost, and durability/maintenance drawbacks. Evidence suggests myoelectric components have similar capability to body-powered prostheses for light work and can provide greater function than passive prostheses when restorative appearance is desired, but performance may decline for heavy work and acceptance rates are similar to body-powered devices.

Emerging technologies: Advanced systems and research include the LUKE/DEKA Arm (multi-joint simultaneous powered movements with sensors and switches), hybrid body-powered/myoelectric systems, development of implantable myoelectric sensors and targeted muscle reinnervation, and sensory feedback technologies (force, pressure, vibration sensors). Evidence for advanced sensor-driven myoelectric components and individually powered digits is limited or insufficient; studies of newer generation devices are needed to determine consistent improvements in function and quality of life.

Evidence topic	Summary
Evidence summary for myoelectric at wrist or above
Limited evidence suggests similar capability to body-powered for light work; appearance advantage over passive; sufficient to determine meaningful improvement when body-powered insufficient.
Evidence summary for sensor/myoelectric controlled components
Insufficient evidence to determine improvement in net health outcome; mixed results in small studies; newer models need further study.
Evidence summary for individually powered digits
No peer-reviewed publications identified; insufficient evidence.

Term	Definition
Passive functional prosthesis
Prosthesis without mechanical working parts that relies on manual repositioning and cannot restore function; lightest and most comfortable.
Body-powered prosthesis
Uses a harness and cable system for functional manipulation driven by voluntary body movements.
Myoelectric prosthesis
Battery-powered prosthesis driven by electromyographic signals from remaining musculature processed to operate motors moving joints.

Revision History

2026-03-16administrative_updateLatest

Administrative update removed codes L6010 and L6020 effective 04/01/2026.

2025-03-12administrative_update

Administrative update added codes L6028-L6033, L6037, L6700, L7406 effective 04/01/2025.

2022-06-01consensus_review

Procedure code L7499 added to policy.

2020-06-10consensus_review

Multiple consensus reviews (2020-2025) noted; policy intent/statement unchanged and references and coding table formatting updated.

Policy Summary

PayerCapital Bluecross

PolicyUpper Limb Prostheses

Policy CodePolicy MP 6.052

Change TypeAdministrative updates; coding additions/removals

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionA certified prosthetist must determine and document that the selected prosthesis is appropriate to meet the member's functional needs.

SourceLink

On This Page

Socket/socket insert replacements: Socket and socket insert replacements may be considered medically necessary if there is documentation of functional and/or physiological need (examples: changes in residual limb, functional need changes, irreparable damage due to wear and tear, wear and tear due to excessive weight, prosthetic demands of a very active amputee).

Terminal devices may be considered medically necessary for work and when essential to ADLs; terminal devices are investigational when used solely for sports or recreation.

All other uses of body-powered prostheses are considered investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Functional evaluation indicates that with training, use of a myoelectric prosthesis is likely to meet the functional needs of the individual (e.g., gripping, releasing, holding, and coordinating movement of the prosthesis) when performing ADLs; evaluation should consider control, durability (maintenance), function (speed, work capability), and usability.

Investigational conditions: Myoelectric upper limb prosthetic components are considered investigational under all other conditions not meeting the above criteria.

Individually powered digits: A prosthesis with individually powered digits, including partial hand prosthesis, is considered investigational.

Replacement timing: Replacement prosthesis: life of a prosthesis is approximately 5 years; replacement may be considered medically necessary only if the previous prosthesis is no longer functional. Requests for upgrades/newer technology will be reviewed for medical necessity.