DraftUnitedHealthcarePolicy CS360KS.02

Upper Extremity Prosthetic Devices (for Kansas Only)

Policy governing medical necessity, coverage, and coding for upper extremity prosthetic devices for members in Kansas, including myoelectric devices and partial-hand components.

Policy Summary

PayerUnitedHealthcare

PolicyUpper Extremity Prosthetic Devices (for Kansas Only)

Policy CodePolicy CS360KS.02

Change TypeApplicable HCPCS codes updated (codes added and descriptions revised)

Effective DateNov 1, 2025

Next Review Date

Key ActionObtain prior authorization when requesting upper extremity prosthetic devices listed by HCPCS L-codes and include required documentation of amputation, functional benefit, prosthetist evaluation, and training ability.

SourceLink

POLICY UPDATE CHANGES

Added HCPCS codes L6034, L6035, L6036, L6038, and L6039 to the list of applicable codes and revised descriptions for L6028 and L7406.

Medically Necessary when ALL criteria metCoverage rationale

KansasApplies to

Extensive L-codesCode ranges

InterQual referencedExternal criteria

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Initial coverage criteria — upper extremity prosthesis

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

Standard general coverage requirements for upper extremity prostheses

Myoelectric, above wrist (external InterQual criteria)

Myoelectric prosthetic for above-wrist amputations

Above-wrist myoelectric: Myoelectric prosthetic for amputations above the wrist is proven and Medically Necessary in certain circumstances; medical necessity clinical coverage criteria are defined by InterQual CP: Durable Medical Equipment, Prosthetics, Myoelectric, Upper Extremity, Above the Wrist (Custom) - UHG

Refer to InterQual criteria (external) for detailed above-wrist myoelectric coverage logic

Myoelectric, below wrist / partial-hand

Covered when ALL of the following are met

Below-wrist myoelectric / partial-hand: 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]; 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 proposal

Specific electromyographic signal requirement noted (3-5 muscle groups typical) and requirement to operate stimulator

Coverage considerations / clinical criteria

Coverage considerations informed by evidence, clinical practice guidelines (VA/DoD), and device/regulatory context

Device selection and prescription: Prescription for upper extremity prostheses should be a collaborative decision between patient and care team and based on a comprehensive assessment including present health status, level of function, modifiable/controllable health risk factors, pain assessment, cognition/behavioral health, personal/family/social/cultural context, learning assessment, residual limb assessment, non-amputated limb and trunk assessment, and prosthetic assessment (design, control strategy, socket, suspension, terminal device, and articulations).

From VA/DoD guidance on prosthesis prescription.

Evidence of benefit: Evidence shows prostheses can reduce functional deficits and joint range of motion (potentially reducing overuse injury risk), and may improve perceived disability and engagement; specific studies report improved SHAP scores for partial-hand users (Wanamaker 2019), DEKA arm users had less perceived disability and greater engagement after training though activity performance varied (Resnik 2018), and classification/training techniques can reduce EMG classification error and improve task metrics (Earley 2016). Outcomes vary by device, training, and study size.

Summarizes multiple study findings.

Myoelectric prosthetic components for hand, partial-hand, and artificial digits below the wrist are considered not Medically Necessary when the member does not meet the specified coverage criteria. Coverage for below‑wrist myoelectric devices requires that the member meet all listed clinical requirements (for example: documented traumatic or surgical amputation below the wrist or congenital missing/dysfunctional hand or finger; the prosthesis replaces all or part of the missing limb; anticipated functional benefit; evaluation and prescription by appropriately qualified prosthetic personnel under physician supervision; willingness and ability to participate in required training; demonstrated ability to operate the device microprocessor/stimulator; completion of functional assessment including ADLs/IADLs; and sufficient residual musculature/electromyographic signal to operate the device).

Regulatory status and clearance do not in themselves determine coverage. FDA approval or clearance is informational only and not a basis for medical necessity. Many prostheses are Class I devices exempt from FDA review; manufacturers and reviewers may reference product codes (for example, GXY, IQZ) for device classification. Notably, the DEKA Arm System received de novo clearance (DEN120016) in 2014 — this clearance is described for informational context but does not substitute for the policy's clinical medical‑necessity requirements.

Devices are not covered when the member cannot use the device or when there is no demonstrated functional benefit. Examples that will lead to noncoverage include inability or unwillingness to participate in training, inability to operate the device stimulator or microprocessor, lack of sufficient residual musculature or electromyographic signal to operate a myoelectric hand (typically requiring activation of about 3–5 muscle groups), or failure to meet any other required clinical criteria documented in the policy.

Pediatric long‑term selection data indicate that children fitted with a variety of prosthetic options do not uniformly select myoelectric devices as their long‑term primary prosthesis. In one long‑term pediatric series, many patients ultimately preferred simpler or passive devices or used multiple prostheses for different functions; only a minority selected myoelectric devices as their primary prosthesis. These findings highlight evidence limitations (small samples, retrospective designs) and support individualized, family‑centered device selection with attention to therapy, family support, and evolving functional needs.

HCPCS / CPT Coding and Code Lists

Upper Limb Prosthetics (selection)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, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at metacarpal level, including flexible or nonflexible interface, molded to patient model, including palm, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by L6692.

Upper Limb Prosthetics (continued)HCPCS

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.
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	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.
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.

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Myoelectric and terminal devicesHCPCS

L6698	Addition to upper extremity prosthesis, lock mechanism, excludes socket insert.
L6700	Upper extremity addition, external powered feature, myoelectronic control module, additional EMG inputs, pattern-recognition decoding intent movement.
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.
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.

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Power, pediatric, elbow/wrist 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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Materials and ancillary additionsHCPCS

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 prosthesis, user adjustable, mechanical, residual limb volume management system (with or without lamination kit).
L8465	Prosthetic shrinker, upper limb, each.

Applicable HCPCS codes updatedHCPCS

L6028	description revised (see policy)
L6034	added (multi-articulation myoelectric hand — new code)
L6035	added
L6036	added
L6038	added
L6039	added
L7406	description revised (see policy)

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for upper extremity prosthetic devices. Verify and obtain prior authorization before ordering or furnishing devices to avoid denial of payment. Prior authorization requirements and benefit determination are governed by the member's contract and applicable federal or state rules; coverage may be denied if the service conflicts with those terms.

Prior authorization required for upper extremity prosthetic devices (including myoelectric prostheses and related HCPCS L-codes).
Verify prior authorization requirements with the member's specific plan and benefit contract before submission.

Billing Rule

Updated Applicable HCPCS Codes — Verify Prior Authorization

Review the updated applicable HCPCS codes and confirm prior authorization applicability for the member's plan. Code edits occur quarterly; use the current code set and plan rules when submitting authorization requests.

New/updated HCPCS codes may affect prior authorization requirements: L6034, L6035, L6036, L6038, L6039 (added 11/01/2025).
Confirm whether newly added or revised codes require separate authorization or documentation per plan.

Documentation Required

Required Documentation to Support Medical Necessity

Provide complete clinical documentation to support medical necessity. Missing or insufficient documentation is a common trigger for denial.

Documentation must demonstrate traumatic or surgical amputation, congenital absence/defect, or clinical indication for prosthesis.
Evidence that the prosthesis will replace all or part of a missing limb and is expected to help the member regain or maintain function.
Physician order and documentation that prosthetic needs were evaluated by a qualified prosthetist or appropriate healthcare professional under physician supervision.
Evidence of the member's willingness and ability to participate in training and rehabilitation.
Functional assessment results (ADLs and IADLs) and rehabilitation potential.

Documentation Required

Required Clinical Assessment and Prescription Components

Include comprehensive clinical assessment and a complete prescription that details the clinical rationale and all device components. Lack of a detailed prescription or incomplete assessment may result in denial.

Comprehensive assessment elements: present health status, level of function, modifiable risk factors, pain assessment, cognition/behavioral health, personal/social context, learning assessment, residual limb assessment, non-amputated limb/trunk assessment, prosthetic assessment, and vocational assessment as applicable.
Prescription must include: design (preparatory vs definitive), control strategy (passive, externally powered, body-powered, task-specific), anatomical side and amputation level, socket interface and frame type, suspension mechanism, terminal device, wrist/elbow/shoulder units (if applicable), and all necessary components and add-ons.
For myoelectric devices, document ability to operate device (e.g., adequate myoelectric signal/microvolt thresholds) and authorization of final prosthetic proposal by the ordering physician.

Step Therapy

Step Therapy / Device Selection Considerations

Device selection should be individualized based on the member's functional goals, rehabilitation potential, and comparative device evidence. There is no mandated step therapy sequence; the care team should determine the most appropriate device collaboratively with the patient.

Consider control strategy (body-powered vs myoelectric vs hybrid) in light of training time, durability, cosmetic outcomes, functional demands, and patient preference.
Review available comparative evidence and clinician/patient goals when selecting device components and terminal devices.
No mandatory trial of one device type is required before another; selection should be individualized.

Note

No Mandated Step Therapy — Individualized Prescription

No mandated step therapy is imposed by this policy. Prescriptions should be individualized and based on a collaborative care-team evaluation of the patient’s needs and goals.

Care team should perform pre-prosthetic training and comprehensive assessment to determine the most appropriate device.
Decisions should reflect input from the patient and all relevant care-team members; personalization is required.

Denial Risk

Denial Triggers for Medical Necessity

Common denial triggers include insufficient documentation, lack of required functional assessment, missing physician authorization, device not supported by plan terms, and conflicts between this policy and the member's benefit contract or state/federal requirements.

Incomplete or absent functional assessments (ADLs/IADLs) or rehabilitation potential documentation.
Missing physician order or lack of documentation that a qualified prosthetist evaluated the member.
Failure to document ability to operate myoelectric device (when applicable) such as insufficient myoelectric signal thresholds.
Submission of codes or devices not covered under the member’s specific benefit plan.
Conflicts between policy guidance and specific federal/state/contractual coverage terms.

Note

Benefit-Term Conflicts May Cause Denial

Coverage is subject to the member's benefit contract and applicable federal or state laws. When conflicts exist between this policy and the member's contract or legal requirements, the contract or law governs and may result in a denial or different coverage determination.

Always check the member's specific plan terms and state/federal mandates before prior authorization and claims submission.
If a conflict exists, follow the federal, state, or contractual requirements that supersede this policy.

Key Definitions

Myoelectric Prosthetic — definition entry for myoelectric prosthetic devices

DefinitionA prosthetic device operated by battery-powered electric motors that are activated through electrodes by myoelectric potentials provided by muscles (Medical Dictionary).

FunctionExternally powered category of upper-limb prostheses that convert electromyographic (EMG) muscle signals into motor-driven movement of terminal devices and articulations.

Typical componentsMay include electrodes, control module, batteries, charger, motors for digits/terminal device, and socket/suspension interfaces.

Clinical requirementsFor below-wrist/partial-hand devices, adequate residual musculature and EMG signal (commonly activation of ~3–5 muscle groups) is required to operate computerized myoelectric hands; training and prosthetist evaluation are needed.

Relation to prosthesis typesClassified as an externally powered prosthesis distinct from body-powered, passive, or hybrid devices; selection depends on level of amputation, patient strength, training ability, and activity demands.

ADLs — Activities of Daily Living definition

DefinitionBasic tasks people need to do to function and interact, such as bathing, grooming, dressing, toilet use, eating, and physical ambulation (Mlinac & Feng 2016; Edemekong et al. 2022).

Purpose in assessmentIncluded in functional assessments used to document expected rehabilitation potential and to demonstrate benefit from a prosthesis.

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

IADLs — Instrumental Activities of Daily Living definition

DefinitionHigher-cognitive and more complex activities related to independent living such as shopping, transportation, meal preparation, housecleaning, managing finances, and managing medications (Mlinac & Feng 2016; Edemekong et al. 2022).

Purpose in assessmentUsed in comprehensive functional evaluations to determine how a prosthesis may support independent living and daily community tasks.

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

Prosthetist — definition of prosthetist role

DefinitionA healthcare professional who makes and fits artificial limbs (prostheses) for people with disabilities.

RolePerforms evaluation of residual limb, fabricates and fits sockets and interfaces, recommends prosthetic components and suspension, and provides adjustments and training in coordination with the ordering physician and rehabilitation team.

Clinical contextProsthetist involvement is required for evaluation and qualification of prosthetic need as part of medical necessity determination for upper-extremity prostheses.

Regulatory status — FDA device class/exemption and DEKA de novo clearance context

FDA device classUpper-limb prostheses are class I devices and are exempt from U.S. Food and Drug Administration (FDA) premarket review (product codes: GXY, IQZ).

Implication for coverageFDA approval or clearance alone is informational and not a basis for coverage decisions under this policy.

DEKA Arm SystemThe DEKA Arm System was cleared via the FDA de novo 513(f)(2) process (DEN120016) in 2014 as a low- to moderate-risk medical device (refer to FDA de novo record).

Pattern-recognition control techniques — definition/explanation of pattern-recognition classifiers and EMG techniques

DefinitionPattern-recognition classifiers use electromyographic (EMG) signals and algorithms to distinguish intended grasps or movements, decoding user intent to control prosthetic functions.

TechniquesApproaches include dual-window classifiers (long and short EMG analysis windows), classification delay or majority-voting methods, and inclusion of EMG from intrinsic hand and extrinsic forearm muscles and static/dynamic wrist motion to improve performance.

Performance impactIncluding intrinsic hand EMG and wrist motion with extrinsic EMG and using dual-window or majority-voting methods significantly reduced classification error (reported 35% reduction) and improved real-time task completion metrics.

Clinical implicationThese classifier and EMG techniques show promise for improving control of partial-hand prostheses and restoring function; training and real-time classifier strategies can reduce selection attempts and task completion time.

OpenPayer

Upper Extremity Prosthetic Devices (for Kansas Only)

Coverage and Medical Necessity Criteria

HCPCS / CPT Coding and Code Lists

Provider Requirements, Authorization, and Documentation

Key Definitions

Background and Evidence Context