UnitedHealthcare upper extremity prosthetic Coverage

Coverage Criteria and Evidence Summary

Non-State-Specific Medical Necessity Criteria

Covered when ALL of the following are met:

Upper extremity prosthesis general medical necessity criteria: Member has a traumatic or surgical amputation of the 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 have been evaluated for the member by a physician, health care professional, or another licensed practitioner of the healing arts acting within the scope of practice authorized under State law, with appropriate prosthetic qualifications and training under the supervision of the ordering physician annually; 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 Activities of Daily Living (ADLs) and Instrumental ADLs] evaluation

All criteria required for medical necessity

Evidence-based coverage stance

Policy stance based on evidence available in this section

Overall evidence summary: Further investigation is needed before the clinical usefulness of bone-anchored percutaneous limb prostheses is proven; existing studies are small, retrospective, and lack comparative outcomes, and uncertainties remain about tissue loading and implant survivorship in vascular amputees.

Statements supported by multiple cited studies and concluding remarks.

A bone-anchored percutaneous limb prosthesis (for example, the OPRA Implant System) is considered not medically necessary for Indiana Medicaid members. The policy concludes the available clinical evidence is insufficient to demonstrate safety and effectiveness, citing limited low-quality studies and reports of high rates of infection and mechanical complications. This device therefore remains unproven and excluded from coverage.

Published series report that osseointegrated arm prostheses have been used in transhumeral (TH) amputations after trauma or tumor but have not been tested in TH amputations resulting from vascular disease; study authors therefore do not recommend their use in that population. Reported implant survival and complications in TH cohorts (small retrospective samples) further limit generalizability.

UnitedHealthcare considers a bone-anchored percutaneous limb prosthesis (such as the OPRA system) unproven and not medically necessary. The policy specifically states that the evidence does not support concluding that the OPRA Implant System is effective and safe because existing studies are few, retrospective, and report concerning infection and mechanical complication rates.

The policy summarizes the evidence stance that the clinical usefulness is unproven and that further investigation is needed before bone-anchored percutaneous limb prostheses can be recommended for routine clinical use. Limitations cited include small sample sizes, retrospective designs, lack of comparative outcomes, and incomplete biomechanical modeling of tissue stress and strain.

Relevant Procedure and Billing Codes

Upper Limb Prosthetics (partial list)HCPCS

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, 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.
L6034	Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at transmetacarpal level, including flexible or non-flexible interface, molded to patient model, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by L6692.

Upper Limb Prosthetics (continued)HCPCS

L6035	Single prosthetic digit, mechanical, can include metacarpophalangeal (MCP), proximal interphalangeal (PIP), and/or distal interphalangeal (DIP) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement.
L6036	Prosthetic thumb, mechanical, can include metacarpophalangeal (MCP), interphalangeal (IP) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement.
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.
L6038	Addition to single prosthetic digit or thumb, mechanical, attachment, multiaxial and/or internal/external rotation/abduction/adduction mechanism, with or without locking feature, any material.
L6039	Passive prosthetic digit or thumb prosthesis not including hand restoration partial hand, full or partial, custom made, any material, initial or replacement, per single passive prosthetic digit or thumb.
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.
L6632	Upper extremity addition, latex suspension sleeve, each.
L6677	Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow.

1–10 of 23

1/3

Upper Limb Prosthetics (additional codes)HCPCS

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, myoelectric 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, myoelectric 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, myoelectric control of terminal device.

1–10 of 30

1/3

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior authorization note

Certain L-codes marked with an asterisk are not managed for medical necessity review for Indiana at the policy effective date. Refer to the UnitedHealthcare Community Plan of Indiana prior authorization and notification list for the most up-to-date information.

Codes labeled with * (see Applicable Codes) are not managed for medical necessity review in Indiana at policy effective date
Verify the current Indiana prior authorization list at Prior Authorization and Notification: UnitedHealthcare Community Plan of Indiana

Note

Verify plan prior authorization

This policy is informational. Plan-specific prior authorization and coverage requirements are governed by the member's federal, state, or contractual benefit plan. Verify the member's benefit plan and any applicable federal or state mandates before rendering services.

Policy is informational and may be superseded by federal, state, or contractual benefit requirements
In the event of conflict, federal, state, or contractual requirements govern

Background and Clinical Context

Upper limb prostheses are used to restore function after traumatic or surgical amputation or in congenital absence or defect. Common device categories include passive (cosmetic), body-powered, externally powered/myoelectric, and hybrid prostheses. Typical amputation levels referenced in clinical assessment and prosthetic prescription include transradial and transhumeral levels, and candidacy requires that the prosthesis will help the member regain or maintain function and that the member is willing and able to participate in training.

Definitions

Activities of Daily Living — definition entry

DefinitionBasic tasks people need to do to function and interact such as bathing, grooming, dressing, toileting, eating, and physically ambulating.

ExamplesBathing, grooming, dressing, toileting, eating, ambulation.

Clinical relevanceUsed in functional assessment to determine rehabilitation potential and need for prosthetic device training.

Instrumental Activities of Daily Living — definition entry

DefinitionHigher cognitive and complex activities related to independent living such as shopping, using transportation, preparing meals, housecleaning, managing finances, and managing medications.

ExamplesShopping, transportation, meal preparation, housecleaning, managing finances, medication management.

Policy Revision History

2026-06-01Policy createdLatest

UnitedHealthcare medical policy CS360IN.03 created as a new medical policy for Indiana Medicaid (Summary of Changes: New Medical Policy).

OpenPayer

Upper Extremity Prosthetic Devices (for Indiana Only)