Upper Extremity Prosthetic Devices (Nebraska)

Coverage Summary

Policy summary

Policy numberCS36ONE.C

Effective date2025-06-01

StateNebraska

Coverage stance for osseointegrationUnproven / Not medically necessary (OPRA / bone‑anchored percutaneous limb prostheses)

Myoelectric above-wrist referralConditional — refer to InterQual CP for medical necessity criteria

Medical Necessity Criteria

Upper Extremity Prosthetic for Amputations - General Medical Necessity

Covered when ALL of the following are met:

ALL of the following

Prosthetic replaces all or part of a missing limb
Member has a traumatic or surgical amputation of upper extremity or a congenital absence or defect
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
Prosthetic device is ordered by or under the direction of a physician
Member is willing and able to participate in the training for the use of the prosthetic

Myoelectric Prosthetic - Above the Wrist (Myoelectric, Custom)

Myoelectric prosthetic for amputations above the wrist is considered medically necessary in certain circumstances per InterQual CP referenced:

Refer to InterQual CP: Durable Medical Equipment; Prosthetics, Myoelectric, Upper Extremity, Above the Wrist (Custom) UHG for medical necessity clinical coverage criteria

Myoelectric Prosthetic Hand/Partial-Hand/Artificial Digits - Below the Wrist

Covered when ALL of the following are met:

Prosthetic replaces all or part of a missing limb

Member has a traumatic or surgical amputation below the wrist or a congenital missing or dysfunctional hand or finger

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 able to operate the stimulator of the computerized prosthetic or microprocessor

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

Myoelectric Prosthetic Components - Not Medically Necessary

Not medically necessary when:

Member does not meet the criteria listed for myoelectric prosthetic hand/partial-hand/artificial digits below the wrist

Bone Anchored Percutaneous Limb Prosthesis (Osseointegration / OPRA)

Coverage stance:

Osseointegrated (bone-anchored percutaneous limb) prostheses are unproven and not medically necessary due to insufficient evidence of efficacy and concerns about infection and mechanical complications

Coverage Rationale (excerpted changes reflected in history)

Policy history indicates coverage position changes and documentation/coverage governance:

Bone-anchored percutaneous limb prosthesis (e.g., Osseoanchored Prostheses for the Rehabilitation of Amputees (OPRA) Implant System) is unproven and not medically necessary due to insufficient evidence of efficacy.

Added to Coverage Rationale 06/01/2025

Benefit coverage determined by federal, state, or contractual requirements; medical records documentation may be required but does not guarantee coverage.

Documentation language added 06/01/2025

Coding (HCPCS / FDA Product Codes)

Referenced HCPCS / L-codes for Upper Limb ProstheticsHCPCS

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 including fingers, flexible or non-flexible interface, endoskeletal system, molded to patient model, for use without external power
L6029	Upper extremity addition, test socket/interface, partial hand including fingers
L6030	Upper extremity addition, external frame, partial hand including fingers
L6031	Addition to upper extremity prosthesis, hand including fingers, ultralight material (partial)
L6032	Addition to upper extremity prosthesis, partial hand including fingers, acrylic material
L6037	Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, partial hand including fingers
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, Otto Bock or equal

1–10 of 55

1/6

Applicable HCPCS codes (updated quarterly per history)HCPCS

L6028
L6029
L6030
L6031
L6032
L6033
L6037
L6698	description revised (per history)
L6700
L7406

FDA Product Codes (informational)mixed

GXY	FDA product code (informational only)
IQZ	FDA product code (informational only)

Provider Actions & Billing

Documentation Required

Functional assessment and documentation required

Document a functional assessment that includes Activities of Daily Living (ADLs) and Instrumental ADLs (IADLs) and record the member’s rehabilitation potential to support medical necessity for a prosthetic. Medical records may be required to assess whether the member meets clinical criteria.

Include ADLs and IADLs evaluation
Describe expected rehabilitation potential

Documentation Required

Prosthetic evaluation by qualified professional

Ensure the prosthetic needs evaluation is performed by a healthcare professional with appropriate prosthetic qualifications and training under the supervision of the ordering physician.

Evaluation by qualified prosthetist or other trained professional

Background & Evidence Summary

This UnitedHealthcare coverage policy (Nebraska only) defines medical necessity criteria, exclusions, and HCPCS code references for upper extremity prosthetic devices, including myoelectric prostheses, partial‑hand devices, and bone‑anchored (osseointegrated) prostheses. Coverage stance: mixed — standard upper extremity prostheses and specified myoelectric devices may be medically necessary when criteria are met, but some technologies are deferred or considered unproven. Effective date: June 1, 2025. State‑specific application: Nebraska only. High‑level positions: myoelectric above‑wrist medical necessity criteria are deferred to InterQual guidance; bone‑anchored percutaneous limb prostheses (e.g., OPRA) are unproven and not medically necessary due to insufficient evidence of efficacy and concerns about complications. The policy notes that documentation and applicable federal/state/contractual requirements govern coverage determinations and that medical records may be requested but do not guarantee coverage.

ref":"b0_0"},{

citations:[

Study / Source	Key findings
Tsikandylakis et al. (2014)	2‑yr implant survival 83%, 5‑yr 80%; 38% 5‑yr incidence of infectious complications; high rates of skin reactions and other adverse events noted
Tereshenko et al. (2024) - systematic review	8 studies met inclusion (retrospective/case series); reported functional improvements and improved ROM/ADLs vs socket prostheses but limited by small sample sizes and heterogeneity
Ortiz‑Catalan et al. (2020/2022 follow‑up)	3–7 year follow‑up in small cohort with neuromusculoskeletal, bone‑anchored prostheses showing intuitive control and sensory feedback; infections and electrode issues reported (one sepsis, one local infection requiring electrode removal)
Hayes HTA (LUKE/DEKA arm) - Hayes 2021, updated 2023	Very low‑quality evidence; device may be safe and allow some patients to perform certain ADLs but functional improvements vs existing prostheses are inconsistent; larger/longer studies needed
Resnik et al. (2018, 2020) - DEKA/LUKE arm studies	DEKA arm associated with lower perceived disability and greater engagement after training; initially slower activity speed that improved with home training; no differences in dexterity or quality of life vs conventional prostheses
Widehammar et al. (2022)	Single‑case/multiple baseline study: multi‑grip myoelectric hands showed improved self‑perceived performance, satisfaction, and wearing time at 6 months but evidence inconclusive and further studies needed
Earley et al. (2016)	Dual‑window EMG classifier techniques reduced pattern‑recognition error and improved real‑time task metrics in non‑amputee and partial‑hand subjects; promising for partial‑hand control
Egermann et al. (2009) - pediatric series	With selection criteria and family support, 76% daily‑use success in young children; small sample and device limitations noted

Definitions

Definitions (key terms)

ADLsBasic tasks such as bathing, grooming, dressing, toilet use, eating, and ambulation

IADLsMore complex activities like shopping, transportation, meal preparation, housecleaning, managing finances, and medications

Myoelectric ProstheticA prosthetic operated by battery-powered electric motors activated through electrodes by myoelectric muscle potentials

ProsthetistA healthcare professional who makes and fits artificial limbs

Prosthesis (upper extremity)Includes body-powered, externally powered/myoelectric, multi-grip myoelectric devices, partial‑hand prostheses, cosmetic devices, and osseointegrated/bone‑anchored systems

OPRAOsseoanchored Prostheses for the Rehabilitation of Amputees implant system (bone‑anchored percutaneous limb prosthesis)

Revision History

2025-06-01policy_changeLatest

06/01/2025: Coverage Rationale updated — bone-anchored percutaneous limb prosthesis (e.g., OPRA Implant System) is designated unproven and not medically necessary due to insufficient evidence of efficacy. (Material change)

2025-06-01policy_changeLatest

06/01/2025: Medical Records Documentation section clarified — benefit coverage determined by federal/state/contract requirements and medical records documentation may be required to assess criteria but does not guarantee coverage.