ModifiedUnitedHealthcarePolicy CS360KS.02

Upper Extremity Prosthetic Devices (for Kansas Only)

This part of the UnitedHealthcare medical policy contains references, instructions for use, and policy history including updates to applicable HCPCS codes for upper limb prosthetic devices; it informs interpretation of standard benefit plan coverage and notes use of InterQual criteria.

Policy Summary

PayerUnitedHealthcare

PolicyUpper Extremity Prosthetic Devices (for Kansas Only)

Policy CodePolicy N/A

Change TypeHCPCS codes added / descriptions revised

Effective DateNovember 1, 2025

Next Review DateN/A

Key ActionWhen deciding coverage, reference federal, state, or contractual benefit plan requirements as they may differ from this standard policy and govern in the event of conflict.

POLICY UPDATE CHANGES

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

Revised descriptions for HCPCS codes L6028 and L7406.

Archived previous policy version CS360KS.01.

5HCPCS codes added

2Descriptions revised

Coverage summary & scope

This coverage criteria brief addresses Upper limb prosthetic devices. The policy status is MODIFIED with last review on 2025-11-01. Effective date and next review are not provided in this extract.

Policy metadata

SubjectUpper limb prosthetic devices - policy references and code updates

StatusMODIFIED

Scope summaryThis part of the UnitedHealthcare medical policy contains references, instructions for use, and policy history including updates to applicable HCPCS codes for upper limb prosthetic devices; it informs interpretation of standard benefit plan coverage and notes use of InterQual criteria.

Last review2025-11-01

Has material changetrue

Medical necessity criteria

No discrete medical-necessity criteria trees are included in this extract. When applicable, InterQual and ASAM criteria are used for primary medical/surgical and SUD coverage determinations per provider guidance; federal, state, or contractual requirements govern coverage decisions when they differ.

Applicable codes

Updated Applicable HCPCS Codes (added/revised)HCPCS

L6034	Added (no description provided in this section)
L6035	Added (no description provided in this section)
L6036	Added (no description provided in this section)
L6038	Added (no description provided in this section)
L6039	Added (no description provided in this section)
L6028	Description revised (exact revised description not provided in this section)
L7406	Description revised (exact revised description not provided in this section)

Quarterly code edits updated the applicable HCPCS list: codes L6034, L6035, L6036, L6038, and L6039 were added, and the descriptions for L6028 and L7406 were revised. The exact revised descriptions are not included in this brief.

Actions for providers

Documentation Required

Follow federal/state/contractual requirements

When deciding coverage, reference federal, state, or contractual benefit plan requirements as they may differ from this standard policy and govern in the event of conflict.

Documentation Required

Use of InterQual and ASAM criteria

UnitedHealthcare uses InterQual for the primary medical/surgical criteria and the American Society of Addiction Medicine (ASAM) criteria for SUD services; if InterQual does not have applicable criteria, UnitedHealthcare may use its Medical Policies approved by the Kansas Department of Health and Environment.

Background & evidence

The background section cites multiple literature references relevant to outcomes and rehabilitation for upper limb prostheses, including systematic reviews, clinical studies, case series, and guideline sources (for example, Resnik et al., VA/DoD CPG 2022, Wanamaker et al., Wang et al., Widehammar et al.).

Instructions for use clarify that this Medical Policy is intended to assist interpretation of UnitedHealthcare standard benefit plans but that federal, state, or contractual benefit plan requirements govern in the event of conflict. UnitedHealthcare uses InterQual for primary medical/surgical criteria and ASAM criteria for SUD services; if InterQual lacks applicable criteria, UnitedHealthcare may use its Medical Policies approved by the Kansas Department of Health and Environment.

Evidence summary

Notable references includedMultiple citations (Resnik et al., VA/DoD CPG 2022, Wanamaker et al. 2019, Wang et al. 2018, Widehammar et al. 2022) relevant to upper limb prosthetic function and outcomes.

Revision history

11/01/2025addedLatest