CurrentColorado Rocky Mountain Health PlansPolicy CS360.D

Upper Extremity Prosthetic Devices

Defines medical necessity criteria, definitions, applicable HCPCS/L codes, and evidence discussion for upper extremity prosthetic devices (including myoelectric devices and bone-anchored osseointegrated prostheses) for Colorado Rocky Mountain Health Plans; excludes specified states. Part 1 of 2 — includes coverage rationale, definitions, applicable codes, descriptions, and evidence summaries.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUpper Extremity Prosthetic Devices

Policy CodePolicy CS360.D

Change TypeCode additions & description revisions; template edit

Effective DateNovember 1, 2025

Next Review DateN/A

Key ActionDocument that the member underwent a functional assessment (including ADLs and IADLs) and is willing/able to participate in prosthetic training.

POLICY UPDATE CHANGES

Template Update removed content/language pertaining to the state of Louisiana.

Added HCPCS codes L6034, L6035, L6036, L6038, and L6039 to applicable codes list.

Revised descriptions for HCPCS codes L6028 and L7406.

Archived previous policy version CS360.C.

1Policy Parts (this is Part 1 of 2)

>50HCPCS/L codes listed

3Coverage categories defined

Cited studies / evidence sources

VA/DoD 2022Clinical guideline referenced

Coverage Summary

This policy (Policy Number CS360.D) is Part 1 of 2 and defines medical necessity criteria for upper extremity prosthetic devices — including myoelectric devices and bone-anchored (osseointegrated) prostheses — for use by clinical and billing/operations staff. It includes coverage rationale, definitions, applicable HCPCS/L codes, and evidence summaries, and is effective November 1, 2025. The policy applies to Colorado Rocky Mountain Health Plans standard benefit interpretation but explicitly excludes certain states listed in the application section (see state-specific policies).

Key policy statistics

Policy Parts (this is Part 1 of 2)1

HCPCS/L codes listed>50

Coverage categories defined3 (general; myoelectric below-wrist; myoelectric above-wrist referenced; osseointegration noted)

Cited studies / evidence sourcesmultiple (systematic reviews, small studies, ECRI/Hayes assessments, Resnik/DEKA studies)

Clinical guideline referencedVA/DoD 2022 Clinical Practice Guideline

Medical-Necessity Criteria

Upper Extremity Prosthetic Devices - General Prosthesis (medically necessary)

An upper extremity prosthetic for amputations is proven and medically necessary when ALL of the following criteria are met:

ALL of the following

Member has a traumatic or surgical amputation of upper extremity or a congenital absence or defect
Prosthetic replaces all or part of a missing limb
Prosthetic will help the member regain or maintain function
Prosthetic device is ordered by or under the direction of a physician

Provider Actions & Billing Notes

Prior Authorization

Ordering physician authorization

Ordering physician must authorize the final prosthetic proposal prior to provision.

Documentation Required

Functional assessment and rehabilitation documentation

Document that the member with expected rehabilitation potential underwent a functional assessment including Activities of Daily Living (ADLs) and Instrumental ADLs (IADLs) and is willing and able to participate in prosthetic training.

ADLs: bathing, grooming, dressing, toileting, eating, ambulation
IADLs: shopping, transportation, meal preparation, housecleaning, managing finances, managing medications

Applicable Codes

Applicable HCPCS L and L-like codes for Upper Limb Prosthetics (reference list)HCPCS

L6026	Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s)
L6028	Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at metacarpal level, including flexible or nonflexible interface, molded to patient model, including palm, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by L6692
L6029	Upper extremity addition, test socket/interface, partial hand including fingers
L6030	Upper extremity addition, external frame, partial hand including fingers
L6031	Replacement socket/interface, partial hand including fingers, molded to patient model, for use with or without external power
L6032	Addition to upper extremity prosthesis, partial hand including fingers, ultralight material (titanium, carbon fiber or equal)
L6033	Addition to upper extremity prosthesis, partial hand including fingers, acrylic material
L6034	Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at transmetacarpal level, including flexible or non-flexible interface, molded to patient model, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by L6692
L6035	Single prosthetic digit, mechanical, can include MCP, PIP, and/or DIP joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement
L6036	Prosthetic thumb, mechanical, can include MCP, IP joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement

1–10 of 61

1/7

Applicable HCPCS codes (updated 11/01/2025)HCPCS

L6034
L6035
L6036
L6038
L6039
L6028	description revised (no text provided in this part)
L7406	description revised (no text provided in this part)

FDA product codes for prostheses (informational)mixed

GXY	FDA product code for prostheses (informational)
IQZ	FDA product code for prostheses (informational)

DEKA Arm de novo clearance (informational)mixed

DEN120016

DEKA Arm System de novo 513(f)(2) classification (2014) - informational

Background, Evidence Summary & Definitions

Upper limb prostheses are classified into four categories — passive, body-powered, externally powered, and hybrid — and are intended to restore function and help members perform Activities of Daily Living (ADLs) and participate in work and daily tasks. The most common amputation levels include transradial (below elbow) and transhumeral (above elbow). This part of the policy provides definitions, a reference list of applicable HCPCS/L codes for upper limb prosthetics (including recently added/revised codes), and evidence summaries addressing myoelectric devices, multigrip hands, powered wrists, and osseointegration studies to support coverage determinations and clinical guidance.

Evidence / Source	Summary
Osseointegration evidence summary
Multiple small retrospective series and case reports show functional gains but high infection/complication rates and limited quality; evidence insufficient to conclude safety and effectiveness.
Myoelectric wrist/hand evidence
Small studies (e.g., Olsen 2024) suggest improved function with powered wrist (reduced task failures and compensatory movements); sample sizes limited and larger comparative studies needed.
PROMIS/DASH correlation
Sabharwal et al. (2023) showed significant correlations between PROMIS Upper Extremity and DASH in a select transhumeral cohort (r = -0.85, p = .002).
ECRI MyoPro 2+ 2024 assessment
ECRI found no published studies specific to MyoPro 2+; available evidence for related devices too limited in quantity and quality to be conclusive.
Hayes Utah Arm brief (2023)
Hayes found insufficient peer-reviewed literature for a full assessment; guideline support for externally powered prostheses appears weak.
Hayes myoelectric multigrip brief (2023)
Hayes reported no/unclear support for myoelectric multigrip hands based on guideline and position statement reviews.
Resnik DEKA arm (DEKA/LUKE)
Resnik et al. (2018): Part A showed less perceived disability but slower activity performance; Part B found improved performance and equivalent speed to conventional prosthesis; no differences in dexterity or quality of life.
Multiple small studies (2019-2024)
Various small studies and single-case series report mixed outcomes for multi-grip and myoelectric devices; evidence is limited by small sample sizes and methodological limitations, leading to inconclusive superiority claims.

Term	Definition
Activities of Daily Living (ADLs)
Basic tasks needed to function such as bathing, grooming, dressing, toileting, eating, and ambulation.
Instrumental Activities of Daily Living (IADLs)
Higher cognitive/complex activities related to independent living such as shopping, transportation, meal preparation, housecleaning, managing finances, and medications.
Myoelectric Prosthetic
A prosthetic device operated by battery-powered electric motors activated through electrodes by myoelectric potentials provided by muscles.
Prosthesis
A man-made substitute for a missing body part.
Prosthetist
A healthcare professional who makes and fits artificial limbs.
Prosthesis (upper extremity)
External device to replace an absent or nonfunctional upper limb; may be passive, body-powered, externally powered, myoelectric, or multi-grip.
Myoelectric prosthesis
A prosthesis that uses electromyography (EMG) signals from residual muscles to control device movements.

Revision History

11/01/2025codes_added

Added HCPCS codes L6034, L6035, L6036, L6038, and L6039 to applicable codes list. (material change)

11/01/2025descriptions_revised

Revised descriptions for HCPCS codes L6028 and L7406. (material change)

04/01/2026template_updateLatest

Template Update removed content/language pertaining to the state of Louisiana. (non-material change)

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUpper Extremity Prosthetic Devices

Policy CodePolicy CS360.D

Change TypeCode additions & description revisions; template edit

Effective DateNovember 1, 2025

Next Review DateN/A

Key ActionDocument that the member underwent a functional assessment (including ADLs and IADLs) and is willing/able to participate in prosthetic training.

On This Page

Prosthetic needs evaluated for member by a healthcare professional with appropriate prosthetic qualifications and training under the supervision of the ordering physician

Member is willing and able to participate in the training for the use of the prosthetic

Member with expected rehabilitation potential undergoes functional assessment (including Activities of Daily Living (ADLs) and Instrumental ADLs (IADLs)) evaluation

Myoelectric Prosthetic - Above the Wrist

An upper extremity Myoelectric Prosthetic for amputations above the wrist is medically necessary in certain circumstances; use InterQual CP: Durable Medical Equipment, Prosthetics, Myoelectric, Upper Extremity, Above the Wrist (Custom) - UHG for clinical criteria.

Coverage requires meeting InterQual criteria referenced in policy (see InterQual CP: Durable Medical Equipment, Prosthetics, Myoelectric, Upper Extremity, Above the Wrist (Custom) - UHG).

Myoelectric Prosthetic hand/partial-hand/artificial digits - Below the Wrist (medically necessary)

A myoelectric prosthetic for amputations below the wrist is medically necessary when ALL of the following criteria are met:

ALL of the following

Member has a traumatic or surgical amputation below the wrist or a congenital missing or dysfunctional hand or finger
Prosthetic replaces all or part of a missing limb
Prosthetic will help the member regain or maintain function
Prosthetic needs evaluated for member by a healthcare professional with appropriate prosthetic qualifications and training under the supervision of the ordering physician
Member is willing and able to participate in the training for the use of the prosthetic
Member is able to operate the stimulator of the computerized prosthetic or microprocessor
Member with expected rehabilitation potential undergoes functional assessment (including ADLs and IADLs) evaluation
muscle_activation_groups: Remaining musculature of the arm(s) contains the minimum microvolt threshold to allow operation of a Myoelectric Prosthetic device (usually 3-5 muscle groups must be activated to use a computerized hand), no external switchusually 3-5 muscle groups must be activated
Include microvolt activation threshold/requirement
Ordering physician authorizes the final prosthetic proposal

Myoelectric Prosthetic components - Not medically necessary

Components are considered not medically necessary when the member does not meet the above criteria:

Myoelectric prosthetic components for hand, partial-hand, and artificial digits below the wrist are not medically necessary in members who do not meet the above criteria

Bone Anchored Percutaneous Limb Prosthesis (osseointegration) - Not medically necessary / Unproven

Bone anchored percutaneous limb prostheses (e.g., OPRA Implant System) are considered unproven and not medically necessary due to insufficient evidence of efficacy and safety:

Available clinical evidence is insufficient to conclude effectiveness and safety due to limited low-quality evidence and high rates of infection and mechanical complications reported in studies

Reasoning: limited low-quality evidence and high rates of infection/mechanical complications

Documentation Required

Prosthetic evaluation by qualified professional

A healthcare professional with appropriate prosthetic qualifications and training must evaluate prosthetic needs under the supervision of the ordering physician; include documentation of the evaluation and supervision.

Evaluator has appropriate prosthetic qualifications and training
Evaluation performed under ordering physician supervision
Documentation retained for review

Denial Risk

Myoelectric component denial if criteria unmet

Claims for myoelectric prosthetic components for hand, partial-hand, and artificial digits below the wrist may be denied if the member does not meet the specified clinical criteria, including adequate muscle microvolt thresholds and ability to operate the device. Remaining musculature must meet the minimum microvolt threshold to allow operation (usually 3–5 muscle groups must be activated to use a computerized hand), and the member must be able to operate the stimulator/microprocessor.

Microvolt threshold: usually requires activation of 3–5 muscle groups
Member must be able to operate the stimulator or microprocessor

Billing Rule

Codes are provided for reference only

The listed HCPCS codes are provided for reference only and inclusion does not guarantee coverage or reimbursement. Benefit coverage is determined by federal, state, or contractual requirements and applicable laws; documentation may be required and coverage is subject to those requirements.

Documentation Required

Use VA/DoD comprehensive assessment for prosthesis prescription

Use the VA/DoD comprehensive assessment approach when prescribing an upper extremity prosthesis; document collaborative decision-making and include device components in the record.

Design (preparatory vs definitive)
Control strategy (passive, externally powered, body powered, task specific)
Anatomical side and amputation level
Socket interface and frame
Suspension mechanism
Terminal device
Wrist, elbow, and shoulder units (if applicable)

Documentation Required

Pre-prosthetic training requirement (VA/DoD guidance)

Ensure patients undergo pre-prosthetic training and a comprehensive assessment prior to prescription; document assessment elements and training readiness.

Present health status
Level of function
Modifiable/controllable health risk factors
Pain assessment
Cognition and behavioral health
Personal, family, social, and cultural context
Learning assessment
Residual limb assessment
Non-amputated limb and trunk assessment
Prosthetic assessment (if applicable)
Vocational assessment

Billing Rule

Reference updated HCPCS codes effective 11/01/2025

Updated HCPCS codes effective 11/01/2025 are included for billing reference. Providers should bill using the updated applicable HCPCS codes list consistent with policy and payer-specific guidance; follow payer instructions for code use and reimbursement.

L6034
L6035
L6036
L6038
L6039
L6028
L7406

11/01/2025archived_supporting_info

Archived previous policy version CS360.C. (non-material change)