DraftUnitedHealthcarePolicy CSNCT0641.03

Upper Extremity Prosthetic Devices (for North Carolina Only)

This policy governs coverage and coding reference for upper extremity prosthetic devices for UnitedHealthcare members in North Carolina; it points providers to North Carolina Medicaid clinical coverage policies for medical necessity criteria.

Policy Summary

PayerUnitedHealthcare

PolicyUpper Extremity Prosthetic Devices (for North Carolina Only)

Policy CodePolicy CSNCT0641.03

Change TypeCode additions and description revision

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionFollow the North Carolina Medicaid Clinical Coverage Policy (Medical Equipment: 5B, Orthotics & Prosthetics) for medical necessity and prior authorization determinations.

SourceLink

POLICY UPDATE CHANGES

Added HCPCS codes L6028, L6029, L6030, L6031, L6032, L6033, L6037, L6700, and L7406 to the list of applicable codes.

Revised description for L6698.

Notated a long list of HCPCS codes that are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

~150+HCPCS L-codes listed or referenced

~30Codes not on NC Medicaid Fee Schedule

NC onlyState-specific applicability

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FDA de novo example cited

5BDelegated medical necessity reference

Coverage and Medical Necessity Criteria

Delegated medical necessity criteria

Coverage and medical necessity determinations

Delegation: Medical necessity clinical coverage criteria are specified in the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Medical Equipment: 5B, Orthotics & Prosthetics.

Providers must refer to NC Medicaid 5B for specific clinical criteria and prior authorization requirements.

Implantable devices and prostheses that are surgically implanted (for example, artificial heart valves) are not considered prosthetics under this policy. If such implantable devices are covered, they are treated and processed as surgical services rather than prosthetic devices.

Certain HCPCS L-codes listed in this policy are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program. Codes specifically not on the NC Medicaid fee schedule include, for example, L6026, L6028, L6029, L6030, L6031, L6032, L6033, L6037, L6384, L6386, L6611, L6621, L6700, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, L7259, L7360, L7364, L7366, L7367, L7368, and L7406 (see Policy History/Revision Information).

Listing a HCPCS code in this policy is provided for reference only and does not imply that the service is covered or that claim payment is guaranteed. Benefit coverage is determined by applicable federal, state, or contractual requirements and laws; other policies or guidelines may also apply and affect coverage or reimbursement.

HCPCS / Coding References

Referenced HCPCS L-codesHCPCS

L6000	Partial hand, thumb remaining.
L6010	Partial hand, little and/or ring finger remaining.
L6020	Partial hand, no finger remaining.
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.

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HCPCS codes added/referenced; many not on NC Medicaid Fee ScheduleHCPCS

L6026	HCPCS code listed as not on NC Medicaid Fee Schedule
L6028	Added to applicable HCPCS codes (also noted not on NC Medicaid Fee Schedule)
L6029	Added to applicable HCPCS codes (also noted not on NC Medicaid Fee Schedule)
L6030	Added to applicable HCPCS codes (also noted not on NC Medicaid Fee Schedule)
L6031	Added to applicable HCPCS codes (also noted not on NC Medicaid Fee Schedule)
L6032	Added to applicable HCPCS codes (also noted not on NC Medicaid Fee Schedule)
L6033	Added to applicable HCPCS codes (also noted not on NC Medicaid Fee Schedule)
L6037	Added to applicable HCPCS codes (also noted not on NC Medicaid Fee Schedule)
L6384	Listed as not on NC Medicaid Fee Schedule
L6386	Listed as not on NC Medicaid Fee Schedule

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State fee schedule inclusion note

State fee schedule inclusionCodes marked with * are not on the NC Medicaid Fee Schedule

ImplicationCodes noted as not on the State of North Carolina Medicaid Fee Schedule may not be covered for NC Medicaid members and claiming them risks denial

Provider actionVerify member’s NC Medicaid fee schedule and benefit terms before billing codes marked with *

FDA de novo year

DeviceDEKA Arm System

Regulatory pathwayCleared by FDA through de novo 513(f)(2)

Provider Responsibilities, Prior Authorization, and Billing Notes

Prior Authorization

Follow NC Medicaid Clinical Coverage Policy (5B)

For medical necessity clinical coverage criteria related to prosthetic devices, providers should refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Medical Equipment: 5B, Orthotics & Prosthetics.

Reference state policy for medical necessity and prior authorization requirements.

Prior Authorization

Prior authorization and benefit verification

Before providing services, verify the member's federal, state, and contractual benefit requirements; these govern coverage when they differ from UnitedHealthcare standard policy. Prior authorization and benefit verification may be required depending on the member's plan.

Check federal/state/contractual benefit terms for the specific member.
Obtain prior authorization when required by the member's benefit plan.

Background and Scope

Upper limb prostheses are artificial devices intended to replace part or all of a missing upper extremity to restore function. The most common amputation levels encountered are transradial (below elbow) and transhumeral (above elbow) (other levels include wrist disarticulation, elbow disarticulation, shoulder disarticulation, and interscapular-thoracic). Prostheses are classified by how they are powered and controlled: passive devices (primarily cosmetic, lightweight, limited mechanical features), body-powered systems (harness-and-cable operation requiring user strength and range of motion), externally powered or myoelectric devices (battery-powered, controlled by EMG or switches, offering more force and more natural function but with added complexity), and hybrid systems that combine body-powered and externally powered components. Choice of device class depends on the amputation level, patient goals, residual limb characteristics, and functional needs.

Key Definitions

Passive prosthesis — definition

DefinitionA lightweight device, often cosmetic, without motors and with limited mechanical features.

Typical useCosmetic restoration and minimal functional support

Distinguishing featureNo motors or externally powered components

Body-powered prosthesis — definition

DefinitionA prosthesis driven by the patient’s movements using a body harness and cable system.

AdvantagesLightweight, durable, may be waterproof

Requirements

Policy Revision History

2025-06-01applicable_codes_updatedLatest

Updated list of applicable HCPCS codes to reflect quarterly edits: added L6028, L6029, L6030, L6031, L6032, L6033, L6037, L6700, and L7406; revised the description for L6698; and added notation that multiple HCPCS codes are not on the State of North Carolina Medicaid Fee Schedule.

Policy Summary

PayerUnitedHealthcare

PolicyUpper Extremity Prosthetic Devices (for North Carolina Only)

Policy CodePolicy CSNCT0641.03

Change TypeCode additions and description revision

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionFollow the North Carolina Medicaid Clinical Coverage Policy (Medical Equipment: 5B, Orthotics & Prosthetics) for medical necessity and prior authorization determinations.

SourceLink

On This Page

Billing Rule

Coding inclusion is not coverage guarantee

Listing of a code in this policy does not imply that the service described by the code is a covered or non‑covered health service. Inclusion of a code does not guarantee reimbursement or claim payment.

Coding inclusion is not a guarantee of coverage or payment.

Documentation Required

Coding and documentation note

Use the HCPCS L‑series codes listed in this policy when submitting claims for prosthetic services. Maintain clinical documentation to support medical necessity and any prior authorization requests. Codes marked with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by NC Medicaid.

Use the listed HCPCS L‑codes when submitting claims.
Maintain supporting documentation of medical necessity and prior authorization (if applicable).
Asterisked codes may not appear on the NC Medicaid fee schedule and may not be covered.

Note

Reference governing benefit terms

When applying this policy, providers must reference the applicable federal, state, or contractual benefit requirements for the member; those terms control in the event of any conflict with this Medical Policy.

Federal, state, or contractual requirements govern over this policy when conflicts exist.

Requires a harness and sufficient user strength and range of motion

Externally powered prosthesis — definition

DefinitionBattery-powered devices controlled by EMG signals, force-sensing resistors, or switches.

AdvantagesGenerate more force and improved cosmetic appearance; minimal harnessing

LimitationsRequire charging, have limited battery life, are more complex and prone to repair needs

Hybrid prosthesis — definition

DefinitionA device combining body-powered components and externally powered (myoelectric) components in one system.

Typical populationOften used for transhumeral and shoulder disarticulation amputees (high-level amputations)

CharacteristicIntegrates mechanical harness-driven elements with battery/EMG-controlled components

DEKA Arm System — definition

NameDEKA Arm System

DescriptionAdvanced upper-limb prosthesis referenced as an example of a de novo-cleared device.

Regulatory noteCleared for marketing by FDA through the de novo 513(f)(2) classification process in 2014

Prostheses device class — definition

Device classProstheses are Class I devices

Regulatory consequenceClass I devices are exempt from U.S. Food and Drug Administration premarket review

Additional infoProduct codes referenced for further information: GXY, IQZ