Upper Extremity Prosthetic Devices

Coverage Criteria and Clinical Rationale

inv-01: General coverage criteria

Covered when ALL of the following are met

General upper extremity prosthesis criteria: Member has a traumatic or surgical amputation of upper extremity or a congenital absence or defect; and Prosthetic replaces all or part of a missing limb; and Prosthetic will help the member regain or maintain function; and Prosthetic device is ordered by or under the direction of a physician; and Prosthetic needs evaluated for member by a healthcare professional with appropriate prosthetic qualifications and training under the supervision of the ordering physician; and Member is willing and able to participate in the training for the use of the prosthetic; and Member with expected rehabilitation potential undergoes functional assessment (including ADLs and IADLs) evaluation

inv-02: Myoelectric (below wrist) coverage criteria

Covered when ALL of the following are met (below wrist myoelectric devices)

Below-wrist myoelectric prosthetic criteria: Member has a traumatic or surgical amputation below the wrist or a congenital missing or dysfunctional hand or finger; and Prosthetic replaces all or part of a missing limb; and Prosthetic will help the member regain or maintain function; and Prosthetic needs evaluated for member by a healthcare professional with appropriate prosthetic qualifications and training under the supervision of the ordering physician; and Member is willing and able to participate in the training for the use of the prosthetic; and Member is able to operate the stimulator of the computerized prosthetic or microprocessor; and Member with expected rehabilitation potential undergoes functional assessment (including ADLs and IADLs) evaluation; and 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 switch; and Ordering physician authorizes the final prosthetic proposalminimum microvolt threshold, usually 3-5 muscle groups

Devices above the wrist (myoelectric) reference InterQual criteria for medical necessity.

inv-03: Bone-anchored percutaneous prostheses

Bone-anchored percutaneous prostheses stance: Bone anchored percutaneous limb Prosthesis (e.g., OPRA Implant System) is unproven and not medically necessary due to insufficient evidence of efficacy

Insufficient/low-quality evidence and high rates of infection and mechanical complications reported

inv-04: Osseointegration candidate considerations

Evidence‑based considerations and typical patient selection described in the studies:

Osseointegration candidate characteristics: Patient selection in reported series included transhumeral amputations primarily from trauma or tumor, prior inability to wear or severe problems with conventional socket prosthesis (eg, very short residual limb), and patient willingness/compliance; use in vascular‑disease amputations was not tested and is uncertain.

Derived from multiple retrospective series and authors' conclusions; further evidence required.

inv-05: Myoelectric and neuromusculoskeletal device evidence

Outcomes reported in small case series and comparative studies:

Neuromusculoskeletal implanted interfaces: Small case series (n=4; 3 with long‑term follow up) report improved intuitive control, sensory feedback referred to phantom hand, functional improvements in ADLs and quality‑of‑life statements; infections and electrode removal were reported in isolated cases; authors call for larger, comparative studies.

Longitudinal follow‑up 3–7 years reported.

Myoelectric multi‑grip vs standard devices: Comparative studies (eg, Kerver et al., n=33) found no clear consistent benefit for multi‑grip devices over standard single‑grip myoelectric hands and noted higher cost and repair considerations; some single‑case or small studies suggest improved satisfaction or task performance with multi‑grip or powered wrists, but evidence is limited and mixed.

Multiple small trials and HTA summaries referenced; results inconclusive.

inv-06: Coverage rationale and evidence-linked statements

Coverage and clinical guidance referenced and supported by VA/DoD guideline and cited studies; notable coverage stance items identified below.

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

policy-level coverage stance

Prosthesis prescription requirements: Prescription should document device design (preparatory vs definitive), control strategy, amputation level, socket interface/frame, suspension mechanism, terminal device, and relevant articulations (wrist/elbow/shoulder) in a collaborative decision between patient and care team (VA/DoD guidance).

clinical documentation expectations

Evidence on multi-grip/myoelectric devices: Studies (Resnik 2018, Earley 2016, others) show mixed results: DEKA users reported less perceived disability and improved engagement after home training but similar dexterity and quality of life compared to conventional prostheses; advanced EMG techniques can reduce classification error and improve control for partial-hand devices.

Myoelectric prosthetic components for a hand, partial-hand, or artificial digits that operate below the wrist are considered not medically necessary when the member does not meet the below‑wrist myoelectric coverage criteria. Required elements include documentation that the amputation or congenital absence is appropriate for a below‑wrist prosthesis; the prosthesis is expected to restore or maintain function; the member is evaluated by a qualified prosthetic professional under the ordering physician; the member is willing and able to participate in training; the member is able to operate the device stimulator or microprocessor; and the member undergoes a functional assessment including ADLs and IADLs. Additionally, the residual musculature must meet the minimum EMG threshold—usually 3–5 muscle groups activated—required to operate a computerized myoelectric hand, and the ordering physician must authorize the final prosthetic proposal.

Bone‑anchored percutaneous limb prostheses (for example, the OPRA Implant System) are considered unproven and not medically necessary because the available clinical evidence is limited and low quality and reports relatively high rates of infectious and mechanical complications. The policy therefore does not support routine coverage of these osseointegrated percutaneous implants.

Reported series of osseointegrated arm prostheses have primarily involved transhumeral (above‑elbow) amputations resulting from trauma or tumor and patients selected for prior inability to tolerate or severe problems with conventional socket suspension (for example, very short residual humerus). Study authors note the approach has not been tested in amputations due to vascular disease and emphasize careful patient selection, documentation of prior socket problems, and the need for comparative studies to establish superiority over socket prostheses.

This Medical Policy does not apply to members in the states of Idaho and Kansas. For those members, refer to the applicable state‑specific policy versions and any contractual or regulatory requirements.

The OPRA Implant System and similar osseointegrated percutaneous limb prosthesis systems are considered unproven and not medically necessary in this policy due to insufficient evidence of efficacy and noted safety concerns in the literature; this coverage stance was added to the policy revision effective 06/01/2025.

Current evidence is insufficient to demonstrate consistent superiority or broad clinical benefit for certain newer devices and systems (for example, the MyoPro 2+, the Utah Arm, and some myoelectric multigrip hands). Systematic and evidence‑assessment reports note limited quantity and quality of studies, and comparative trials (including Kerver et al., n=33) have not shown clear, consistent advantages for multi‑grip devices over standard myoelectric hands.

Restating the policy stance: bone‑anchored percutaneous limb prostheses (including OPRA) are considered unproven and not medically necessary because available studies are small, retrospective, and report notable rates of infection and mechanical complications that limit conclusions about long‑term efficacy and safety.

Applicable HCPCS / L-codes and Coding Notes

Applicable L6xxx additions and modules (part 1)HCPCS

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.
L6694	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism.
L6695	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism.
L6696	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only.
L6697	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only.
L6698	Addition to upper extremity prosthesis, lock mechanism, excludes socket insert.

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Applicable L68xx myoelectric and socket codesHCPCS

L6880	Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s).
L6881	Automatic grasp feature, addition to upper limb electric prosthetic terminal device.
L6882	Microprocessor control feature, addition to upper limb prosthetic terminal device.
L6883	Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power.
L6884	Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power.
L6890	Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment.
L6925	Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device.
L6935	Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device.
L6945	Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device.
L6955	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control

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Applicable L70xx-L73xx batteries and control componentsHCPCS

L7007	Electric hand, switch or myoelectric controlled, adult.
L7008	Electric hand, switch or myoelectric, controlled, pediatric.
L7009	Electric hook, switch or myoelectric controlled, adult.
L7045	Electric hook, switch or myoelectric controlled, pediatric.
L7180	Electronic elbow, microprocessor sequential control of elbow and terminal device.
L7181	Electronic elbow, microprocessor simultaneous control of elbow and terminal device.
L7190	Electronic elbow, adolescent, variety village or equal, myoelectronically controlled.
L7191	Electronic elbow, child, variety village or equal, myoelectronically controlled.
L7259	Electronic wrist rotator, any type.
L7360	Six volt battery, each.

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Applicable L74xx additions and miscellaneous codesHCPCS

L7400	Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal).
L7401	Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal).
L7403	Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material.
L7404	Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material.
L7406	Addition to upper extremity, user adjustable, mechanical, residual limb volume management system.
L8465	Prosthetic shrinker, upper limb, each.

Updated Applicable HCPCS CodesHCPCS

L6028	Added HCPCS code (description updated in policy)
L6029	Added HCPCS code (description updated in policy)
L6030	Added HCPCS code (description updated in policy)
L6031	Added HCPCS code (description updated in policy)
L6032	Added HCPCS code (description updated in policy)
L6033	Added HCPCS code (description updated in policy)
L6037	Added HCPCS code (description updated in policy)
L6700	Added HCPCS code (description updated in policy)
L7406	Added HCPCS code (description updated in policy)
L6698	Description revised per policy

Minimum muscle groups for myoelectric operation

Minimum muscle groupsUsually 3–5 residual muscle groups must be activated (minimum microvolt threshold) to operate a myoelectric below‑wrist prosthesis

Operational requirementRemaining musculature must provide sufficient myoelectric signal amplitude (microvolt threshold) without use of an external switch

Functional assessment tie‑inMember must undergo functional assessment including ADLs and IADLs to document ability to use the myoelectric device

Prior Authorization, Documentation, and Clinical Steps

Prior Authorization

Obtain prior authorization per medical necessity criteria

Prior authorization is required for upper extremity prosthetics and myoelectric devices; the ordering physician must authorize the final prosthetic proposal and a qualified prosthetic professional must evaluate prosthetic needs under physician supervision per the medical necessity criteria.

Prior authorization applies to listed HCPCS L-codes for upper extremity prostheses and myoelectric components (see policy coding).
Ordering physician must authorize the final prosthetic proposal after prosthetic evaluation.

Prior Authorization

Advise prior authorization and justify osseointegration in non‑trauma cases

Osseointegration (bone‑anchored percutaneous implants) has been reported mainly in transhumeral amputations from trauma or tumor; use in vascular‑disease amputations is uncertain and may require explicit justification or prior authorization.

Reported series selected patients with trauma/tumor etiology and prior inability to wear conventional sockets.

Background and Scope

Upper limb prostheses are used to restore function after transradial (below‑elbow) and transhumeral (above‑elbow) amputations and include device classes such as passive (cosmetic), body‑powered, externally powered (myoelectric), and hybrid systems. Myoelectric prostheses are battery‑powered devices controlled by surface EMG electrodes that require adequate residual musculature and training to operate. Clinical evaluation should include a comprehensive assessment of functional goals, ADLs and IADLs, and a prosthetic evaluation by a qualified prosthetist under physician supervision to determine the appropriate device and expected rehabilitation potential.

Key Definitions

Activities of Daily Living (ADLs)

DefinitionBasic tasks people need to do to function and interact such as bathing, grooming, dressing, toilet use, eating, and physical ambulation.

Use in policyADL assessment is required as part of the functional evaluation for prosthesis candidacy.

ReferencesMlinac & Feng (2016); Edemekong et al. (2022) cited for ADL definition.

Instrumental Activities of Daily Living (IADLs)

DefinitionHigher cognitive and complex activities related to independent living such as shopping, transportation, meal preparation, housecleaning, managing finances, and managing medications.

Use in policyIADL assessment is required as part of the functional evaluation for prosthesis candidacy.

Policy Change History

2025-06-01policy_revisionLatest

Policy updated: added exclusion that this Medical Policy does not apply to Idaho and Kansas; clarified medical records documentation requirements and updated Clinical Evidence and References.

2025-06-01coverage_stance_change

Added material coverage stance that bone-anchored percutaneous limb prostheses (e.g., OPRA Implant System) are considered unproven and not medically necessary due to insufficient evidence of efficacy.

2025-06-01