CurrentUnitedHealthcarePolicy CS360ID.C

Upper Extremity Prosthetic Devices (for Idaho Only)

Defines UnitedHealthcare's Idaho-specific policy referencing Idaho Medicaid clinical coverage criteria for medical necessity of upper extremity prosthetic devices and lists applicable HCPCS codes and documentation requirements; applies to Idaho including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

PolicyUpper Extremity Prosthetic Devices (for Idaho Only)

Policy CodePolicy CS360ID.C

Change TypeDocumentation clarifications (material) and link removal

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain and maintain legible medical record documentation that fully supports medical necessity, including history, physical exam, and pertinent diagnostic results, and make it available upon request.

SourceLink

POLICY UPDATE CHANGES

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services.

Reference link to the guidelines titled Medical Records Documentation Used for Reviews was removed.

Idahogeographic application

1+ listsHCPCS procedure codes listed

Idaho Medicaid Handbookclinical criteria source

Coverage Criteria

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Coding and HCPCS

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).

Upper Limb Prosthetics (additional)HCPCS

L6028	Partial hand including fingers, flexible or non-flexible interface, endoskeletal system, molded to patient model, for use without external power, 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.
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.

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Socket and accessory additionsHCPCS

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 (for other than initial, use code L6694 or L6695).
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 (for other than initial, use code L6694 or L6695).
L6698	Addition to upper extremity prosthesis, lock mechanism, excludes socket insert.

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Terminal devices and socketsHCPCS

L6715	Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement.
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.

Upper limb powered prostheses and accessoriesHCPCS

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 of terminal device.
L6975	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, myoelectronic control of terminal device.
L7007	Electric hand, switch or myoelectric controlled, adult.
L7009	Electric hook, switch or myoelectric controlled, adult.
L7180	Electronic elbow, microprocessor sequential control of elbow and terminal device.
L7181	Electronic elbow, microprocessor simultaneous control of elbow and terminal device.
L7259	Electronic wrist rotator, any type.

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No clinical thresholds in policy (inv-08)

Clinical thresholdsThis policy does not specify any numeric clinical thresholds or measurable cutoffs for medical necessity; clinical criteria are determined by the Idaho Medicaid Provider Handbook.

Implication for providersDo not rely on numeric thresholds in this policy — follow the Idaho Medicaid clinical criteria and document clinical findings per handbook requirements.

Billing/coding impactCodes listed in the policy are for reference only; inclusion does not imply coverage determination based on numeric thresholds.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Refer to Idaho Medicaid clinical criteria — providers must follow Idaho Medicaid criteria and obtain prior authorization as required.

Applies to Idaho Medicaid Plus plans and all Idaho members covered under this policy

Note

Provider Action

Providers must follow Idaho Medicaid clinical criteria. Ensure prior authorization is obtained when required by Idaho Medicaid guidelines.

Documentation Required

Required Medical Record Documentation

The patient's medical record must contain legible documentation that fully supports the medical necessity for the requested services. This includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation must be maintained in the patient's medical record and made available upon request.

Denial Risk

Documentation-Related Denial Risk

Lack of sufficient documentation—such as missing history, physical exam findings, or pertinent test results—may result in denial of the request.

Include history, exam, and relevant diagnostic test results
Maintain legible records and produce on request

OpenPayer

Upper Extremity Prosthetic Devices (for Idaho Only)

Coverage Criteria

Coding and HCPCS

Provider Actions and Documentation Requirements

Background

Definitions