Modifiedhusky_healthPolicy N/A

Body-powered and Myoelectric Upper Limb Prostheses

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Defines medical necessity criteria, prior authorization requirements, documentation, coding, and coverage stance for body-powered and myoelectric upper limb prostheses for Connecticut Medicaid (HUSKY Health) providers.

Policy Summary

Payerhusky_health

PolicyBody-powered and Myoelectric Upper Limb Prostheses

Policy CodePolicy N/A

Change TypeMaterial updates to repair/replacement, documentation timing, codes, and Not Medically Necessary list

Effective DateNov 1, 2024

Last ReviewDec 26, 2025

Next Review DateN/A

Key ActionSubmit a fully completed online prior authorization request with a signed prescription and clinical documentation (all within the past 3 months) to support medical necessity.

SourceLink

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Modifiedhusky_healthPolicy N/A

Body-powered and Myoelectric Upper Limb Prostheses

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Policy Summary

Payerhusky_health

PolicyBody-powered and Myoelectric Upper Limb Prostheses

Policy CodePolicy N/A

Change TypeMaterial updates to repair/replacement, documentation timing, codes, and Not Medically Necessary list

Effective DateNov 1, 2024

Last ReviewDec 26, 2025

Next Review DateN/A

Key ActionSubmit a fully completed online prior authorization request with a signed prescription and clinical documentation (all within the past 3 months) to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Language throughout policy updated to reflect 'limb' versus 'arm' and to standardize singular/plural forms of orthosis/orthoses and prosthesis/prostheses.

Repair and replacement language updated with clarified medical necessity criteria and added required documentation for repairs/replacements.

Procedure updated to reflect prescription and documentation timing changed to within 3 months (from prior 12 and 6 month timeframes).

Codes section updated to reflect new codes and code changes.

Not Medically Necessary section updated to include additional devices and HCPCS codes considered investigational and cosmetic prosthetic additions.

2types of prostheses

Requiredprior authorization

~50+HCPCS L-codes reviewed

AppliesEPSDT

3HUSKY categories

Coverage Criteria for Upper Limb Prostheses

inv-01: Body-powered prosthesis - Initial coverage criteria

Covered when ALL of the following are met:

Body-powered criteria: A. The individual has a traumatic or surgical amputation, or congenital absence or defect of an upper extremity and the prosthesis will replace all or part of the missing limb; B. The prosthesis is ordered by the individual's treating physician, advanced practice registered nurse (APRN), or physician assistant (PA); C. All surgical revisions have been completed and the residual arm is fully healed (typically 6 months post amputation or last surgical revision) and can support the requested prosthesis/components; D. The individual has been evaluated by an independent qualified professional (e.g., prosthetist) to determine the most appropriate prosthesis, prosthetic components, and control mechanism; E. A functional evaluation indicates that with training, use of a body-powered prosthesis is likely to meet the functional needs of the individual when performing activities of daily living (ADLs); F. The individual is willing to participate in training on the safe use of the prosthesis, is motivated to use the device, and understands the physical limitations of the prosthesis/component(s); G. For children who are still growing, the requested prosthesis/component(s) is designed to allow for growth adjustments.

inv-02: Myoelectric prosthesis - Initial coverage criteria

Covered when ALL of the following are met:

Myoelectric criteria: A. The individual has a traumatic or surgical amputation, or congenital absence or defect of an upper extremity and the prosthesis will replace all or part of the missing limb; B. The prosthesis is ordered by the individual's treating physician, APRN, or PA; C. All surgical revisions have been completed and the residual arm is fully healed (typically 6 months post amputation or last surgical revision) and can support the requested prosthesis/component(s); D. The individual has been evaluated by an independent qualified professional (e.g., prosthetist) to determine the most appropriate prosthesis, prosthetic components, and control mechanism; E. A standard or body-powered prosthesis cannot be used or is insufficient to meet the functional needs of the individual in performing activities of daily living (ADLs); F. There is documentation that the remaining muscles of the arm can tolerate the weight of the requested myoelectric prosthesis (through manual muscle testing and/or documented simulation); G. The individual is free of comorbidities that could interfere with function of the prosthesis (e.g., neuromuscular disease); H. The individual is able to operate the simulator or microprocessor of the computerized prosthetic; I. A functional evaluation indicates that with training, use of a myoelectric prosthesis is likely to meet the functional needs of the individual when performing ADLs; J. The individual is willing to participate in training on the safe use of the prosthesis, is motivated to use, and understands its physical limitations.

inv-03: Repair and replacement

Covered when ALL of the following are met:

Repair/replacement criteria: A. The above criteria for a body-powered upper limb prosthesis or a myoelectric upper limb prosthesis are met; and B. There is unrepairable damage to the prosthesis and/or prosthetic component(s); or C. There is a reported loss of the prosthesis and/or prosthetic component(s); or D. There has been a change in the individual's condition and the current prosthesis is not meeting the individual's functional needs.

Custom fabricated gloves billed with HCPCS code L6895 are considered not medically necessary. The policy specifies these items are primarily cosmetic in nature and are not used to treat a medical condition, therefore they do not meet coverage criteria for body-powered or myoelectric upper limb prostheses.

Additions to an upper limb prosthesis that solely address appearance (for example, matching skin tone, veins, hair, wrinkles, or painted nails) and do not contribute to restoration of function will also be considered not medically necessary.

The Not Medically Necessary section has been expanded to explicitly identify additional devices and HCPCS codes that are considered investigational or cosmetic and therefore not covered. This update aligns terminology (limb vs. arm) and clarifies which prosthetic additions are considered cosmetic in nature.

Providers should note the examples in the updated section, which reinforce that items lacking clinical utility or intended only to improve appearance do not meet medical necessity requirements and may be denied at authorization or claim review.

Specific myoelectric components are identified in policy as investigational and not medically necessary due to insufficient peer-reviewed evidence. Notable examples listed include HCPCS L6880 (prosthetic whole hand attachment with individually powered/multi-articulating fingers) and HCPCS L6026 (myoelectric partial hand with individually powered fingers).

The policy also lists advanced combination sensor/myoelectric modules (e.g., L7499, L6700) and myoelectric-controlled orthoses (e.g., L8701, L8702) as investigational and not medically necessary.

In summary, the policy classifies a set of upper limb prosthetic devices and HCPCS codes as either investigational or not medically necessary. Examples called out in the Not Medically Necessary section include multi‑articulating myoelectric hands and individually powered digits (L6880, L6026), advanced sensor/myoelectric control modules (L7499, L6700), myoelectric-controlled orthoses (L8701, L8702), and cosmetic additions such as custom fabricated gloves (L6895).

Cross-reference the Not Medically Necessary section when preparing prior authorization requests or coding determinations, since devices listed there are subject to denial for lack of demonstrated medical benefit.

Coding and Billing (HCPCS / CPT / L-codes)

Codes Reviewed Using PolicyHCPCS

L6000	Upper Limb Prosthesis - Wrist, Hand, and/or Finger
L6010	Partial hand prosthesis, thumb remaining
L6020	Partial hand prosthesis, little and/or ring finger remaining
L6026	Myoelectric partial hand with individually powered fingers (listed as investigational in policy)
L6029	Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power
L6030	Upper extremity addition, test socket/interface, partial hand including fingers
L6031	Replacement socket/interface, partial hand including fingers, molded to patient model
L6032	Addition to upper extremity prosthesis, partial hand including fingers, ultralight material
L6033	Addition to upper extremity prosthesis, partial hand including fingers, acrylic material
L6034	Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, transmetacarpal level

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Codes Reviewed Using PolicyHCPCS

L6940	locking hinges, forearm, Otto Bock or equal switch
L6970	Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device
L6700	Upper Extremity Addition, External Powered Feature, Myoelectonic Control Module
L7040	Prehensile actuator, switch controlled
L7170	Electronic elbow, Hosmer or equal, switch controlled
L7185	Electronic elbow, adolescent, Variety Village or equal, switch controlled
L7186	Electronic elbow, child, Variety Village or equal, switch controlled
L7499	Upper extremity prosthesis, not otherwise specified
L9900	Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS 'L'

Codes Reviewed Using InterQual Criteria / Detailed L-code listHCPCS

L6611	Addition to upper extremity prosthesis, external powered, additional switch, any type
L6621	Upper extremity prosthesis addition, flexion/extension wrist, with or without friction, for use with external powered terminal device
L6629	Upper extremity addition, quick disconnect lamination collar with coupling piece
L6632	Addition to upper extremity prosthesis, latex suspension sleeve, each
L6677	Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow
L6680	Upper extremity addition, test socket, wrist disarticulation or below elbow
L6682	Upper extremity addition, test socket, elbow disarticulation or above elbow
L6686	Upper extremity addition, suction socket
L6687	Upper extremity addition, frame type socket, below elbow or wrist disarticulation
L6688	Upper extremity addition, frame type socket, above elbow or elbow disarticulation

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inv-11: Authorization basis

Authorization basisMedical necessity at the time the authorization is issued (authorization is not a guarantee of payment; payment depends on active coverage, benefits and policies in effect at time of service)

Prior Authorization, Documentation, and Provider Guidance

Prior Authorization

Prior authorization required

Prior authorization is required for body-powered and myoelectric upper limb prostheses; requests are reviewed per the DME prior authorization procedures and are evaluated using case-specific clinical information.

Note

Where to check authorization specifics

Consult the Benefit and Authorization Grids on www.ct.gov/husky and the CMAP provider fee schedules and regulations at www.ctdssmap.com to determine whether prior authorization is required and for definitive benefit and service limitation details.

Step Therapy

Step-up requirement for myoelectric devices

Approval of a myoelectric prosthesis requires documentation that a standard or body-powered prosthesis cannot be used or is insufficient to meet the individual's activities-of-daily-living (ADL) functional needs.

Definitions and Program Categories

inv-21: Body-powered upper limb prosthesis

DefinitionA prosthesis that uses body movements, harnessed with control snaps and cables, to mobilize a terminal device (e.g., hook or hand).

Typical componentsSocket, method of suspension, harness and control cables, terminal device (hook or mechanical hand).

Primary control methodUser-generated body motions transmitted via harness/cables to operate the terminal device.

inv-22: Myoelectric upper limb prosthesis

DefinitionA prosthesis that uses surface electrodes embedded in the socket to detect and amplify electrical activity of the residual limb muscles to facilitate movement.

Primary componentsEmbedded surface electrodes, power source (batteries), myoelectric control module, socket and terminal device.

Background

An upper limb prosthesis replaces or compensates for a missing limb or part of a limb and may include components for the hand, wrist, elbow, and/or shoulder. Prostheses are composed of a socket or interface, structural components, terminal devices, and, when applicable, control systems and power sources.

A body-powered prosthesis uses harnessed body movements and mechanical linkages (cables, control snaps) to operate a terminal device, while a myoelectric prosthesis uses surface electrodes embedded in the socket to detect and amplify electrical activity from residual limb muscles to drive powered components. These distinctions guide evaluation, training, and medical necessity determinations.

Policy Revision History

2025-12-26approvalLatest

Policy updates (language standardization, repair/replacement criteria and documentation timing, Not Medically Necessary additions, and code updates) approved by DSS following Medical Reviewer and Clinical Quality Subcommittee review.

2025-12-15committee_approval

CHNCT Clinical Quality Subcommittee approved the updated policy reflecting terminology changes, revised repair/replacement criteria, documentation timing updates, new required documentation for repairs/replacements, and Not Medically Necessary code additions.

Policy Summary

Payerhusky_health

PolicyBody-powered and Myoelectric Upper Limb Prostheses

Policy CodePolicy N/A

Change TypeMaterial updates to repair/replacement, documentation timing, codes, and Not Medically Necessary list

Effective DateNov 1, 2024

Last ReviewDec 26, 2025

Next Review DateN/A

Key ActionSubmit a fully completed online prior authorization request with a signed prescription and clinical documentation (all within the past 3 months) to support medical necessity.

SourceLink

On This Page

Note

Authorization is not a payment guarantee

Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment; payment depends on the individual's active coverage, benefits, and policies in effect at the time of service.

Documentation Required

Required documentation to submit

Submit a fully completed online authorization request, a signed prescription dated within the past 3 months, a progress note within the past 3 months documenting limb status and cognitive/functional ability, clinical documentation from a qualified professional supporting medical necessity, and for repairs/replacements include documentation of the reason.

Fully completed authorization request via online web portal
Signed prescription within the past 3 months from treating physician/APRN/PA enrolled in CMAP
Progress note within the past 3 months documenting affected limb status and individual's cognitive/functional ability
Clinical documentation from a qualified professional (e.g., prosthetist) supporting medical necessity
For repairs/replacements: documentation of reason (damage, loss, or change in condition)

Documentation Required

Documentation and timing updates

Documentation requirements for repairs/replacements were added and prescription and documentation timing were revised to within 3 months to align with other orthoses and prostheses policies.

Added required documentation for repair or replacement (reason for repair/replacement)
Prescription and progress note timing revised to within 3 months

Denial Risk

Denial triggers — insufficient documentation or investigational devices

Requests that do not include documentation showing the individual meets the clinical criteria — for example, healed residual limb (typically ~6 months post-amputation or last surgical revision), evaluation by a qualified prosthetist, and functional evidence that supports need — or requests for devices listed as investigational may be denied.

Evidence residual limb is fully healed (typically 6 months post amputation or last revision)
Evaluation by an independent qualified professional (prosthetist)
Functional evaluation demonstrating need (ADL limitations)
Requests for investigational devices (e.g., listed HCPCS codes) risk denial

Billing Rule

Authorization vs. payment

Authorizations are issued based on medical necessity at the time of the request and do not guarantee payment; actual payment is contingent on the member having active coverage and applicable benefits and policies in effect at the time of service.

Clinical requirementCandidate must have sufficient residual muscle activity (documented by manual muscle testing or simulation) and be free of comorbidities that interfere with prosthesis function.

inv-23: HUSKY program categories

HUSKY program listHUSKY A, HUSKY B, HUSKY C, HUSKY D, and the HUSKY Limited Benefit Program (collectively the HUSKY Health Program).

HUSKY AConnecticut children and their parents or a relative caregiver; pregnant women may qualify; income limits apply.

HUSKY BUninsured children under 19 in higher income households; family cost-sharing may apply.

HUSKY CResidents age 65+ or ages 18–64 who are blind or have another disability; includes MED-Connect; income and asset limits apply.

HUSKY DResidents ages 19–64 without dependent children who do not qualify for HUSKY A, do not receive Medicare, and are not pregnant (lowest-income Medicaid).

HUSKY Limited Benefit ProgramLimited Medicaid coverage for individuals with tuberculosis or for family planning; substantially less than full Medicaid coverage.

inv-24: Medically Necessary

Medically Necessary (per Connecticut statute)Health services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate a condition and its effects to attain or maintain achievable health and independent functioning, consistent with generally accepted standards of medical practice and clinically appropriate in type, frequency, timing, site, extent and duration.

Additional criteriaNot primarily for convenience; not more costly than an alternative that is at least as likely to produce equivalent results; based on an assessment of the individual and their medical condition.

Evidence basisServices must be consistent with credible scientific evidence, specialty society recommendations, practicing physicians' views, and other relevant factors.

medical_reviewer_review

Changes to language, repair/replacement criteria, procedure timing, Not Medically Necessary section, and codes were reviewed and approved at the Medical Reviewer meeting.

2024-12-27approval

Initial approvals for the original publication were completed by DSS following Medical Reviewer and Clinical Quality Subcommittee review in late 2024.

2024-11-13medical_reviewer_approval

Original publication was approved at the Medical Reviewer meeting as part of the initial release in November 2024.