ModifiedUnitedHealthcarePolicy N/A

Upper Extremity Prosthetic Devices (for New Mexico Only)

This policy section reviews clinical evidence, guideline recommendations, and applicable HCPCS codes for myoelectric hands, partial-hand devices, artificial digits, and advanced externally powered/osseointegrated upper-extremity prostheses; it provides clinical background and lists updated applicable HCPCS codes. It is intended to guide UnitedHealthcare coverage decisions and coding for upper-extremity prosthetic devices.

Policy Summary

PayerUnitedHealthcare

PolicyUpper Extremity Prosthetic Devices (for New Mexico Only)

Policy CodePolicy N/A

Change TypeHCPCS codes added/revised (11/01/2025)

Effective DateNovember 1, 2025

Next Review Date

Key ActionProviders must document a comprehensive assessment including present health, function level, pain, cognition, learning ability, residual limb and contralateral limb status, prosthetic assessment and vocational needs, and include device design, control strategy, anatomical side/level, socket type, suspension method, terminal device and applicable joint units in the prescription.

SourceLink

POLICY UPDATE CHANGES

Added HCPCS codes L6034, L6035, L6036, L6038, and L6039 to applicable codes.

Revised descriptions for HCPCS codes L6028 and L7406.

Archived previous policy version CS360NM.B.

MultipleStudies reviewed (years 2002-2024)

LowOverall quality of evidence

VA/DoD 2022Guideline referenced

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5HCPCS codes added/revised in 11/01/2025 update

Coverage summary and scope

This policy section reviews clinical evidence, guideline recommendations, and updated HCPCS coding for myoelectric hands, partial-hand devices, artificial digits, and advanced externally powered and osseointegrated upper-extremity prostheses. It is intended to guide UnitedHealthcare coverage decisions and coding for these devices. The coverage stance is mixed based on a body of evidence judged to be of Low overall quality, references the VA/DoD 2022 guideline for assessment and prescription, and reflects 5 HCPCS codes added or revised in the 11/01/2025 update.

Key summary

Studies reviewedMultiple (years 2002-2024)

Overall quality of evidenceLow

Guideline referencedVA/DoD 2022

HCPCS codes added/revised in 11/01/2025 updateAdded L6034, L6035, L6036, L6038, L6039; revised L6028, L7406 (5 added)

Clinical evidence summary and prescription considerations

Evidence and guideline-based considerations for use and prescription of upper-extremity myoelectric and externally powered prostheses:

Evidence quality and device-level findings: Evidence for multi-grip myoelectric prosthetic hands and advanced externally powered arms is limited, of low quality, and inconsistent; studies include small case series, observational cohorts, cross-over and single-case designs.
Comparative functional outcomes: No clear consistent superiority of multi-grip myoelectric hands (MHP) over standard single-grip myoelectric hands (SHP) in functional outcomes; some studies show SHP outperform MHP in several measures.
Advanced externally powered arms (DEKA/LUKE): Some devices (e.g., DEKA/LUKE arm) may allow performance of certain ADLs for some patients but evidence is inconsistent and limited; may improve perceived disability and engagement but not uniformly superior in dexterity or quality-of-life metrics.
Guideline/consensus prescription requirements

Device-specific findings and limitations

Technology-specific findings / Limitations

Device-specific evidence statements and limitations:

MyoPro 2+: no published studies specifying use; evidence too limited to be conclusive (ECRI assessment).
Utah Arm (Fillauer Motion Control): insufficient peer-reviewed literature for full assessment (Hayes 2023).
Myoelectric multigrip hands: Myoelectric multigrip prosthetic hands: guidance appears to confer no or unclear support for use (Hayes 2023).
LUKE/DEKA Arm: very low-quality evidence; may be safe and allow some ADLs but inconsistent improvement vs existing prostheses (Hayes 2021/2023 update).

Applicable codes and informational product codes

Applicable HCPCS codes (updated list)HCPCSCovered

L6028	Revised description (see policy history)
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	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.
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.
L7406	Revised description (see policy history)

FDA product codes (informational)mixed

GXY	FDA product code for prostheses (informational)
IQZ	FDA product code for prostheses (informational)

Policy changes effective 11/01/2025 include addition of HCPCS codes L6034, L6035, L6036, L6038, and L6039, and revisions to the descriptions for L6028 and L7406 as noted in the policy history.

Documentation, training, and billing actions

Documentation Required

Comprehensive pre-prosthetic assessment and individualized prescription

Document a comprehensive pre‑prosthetic assessment and an individualized prosthetic prescription that addresses medical, functional, and device-specific factors.

Present health status
Level of function
Pain assessment
Cognition and behavioral health
Learning assessment
Residual limb assessment
Non‑amputated (contralateral) limb and trunk assessment
Prosthetic assessment (if applicable)
Vocational assessment
Device design (preparatory vs. definitive)
Control strategy (passive, externally powered, body‑powered, task‑specific)
Anatomical side and amputation level
Socket interface and socket frame

Clinical background, evidence sources, and definitions

The background summarizes evidence from systematic reviews, single-case studies, cross-sectional surveys, and technology assessments (ECRI, Hayes) evaluating myoelectric and externally powered upper-extremity prostheses. The VA/DoD 2022 guideline recommends team-based comprehensive assessment and individualized prosthesis prescription, including pre-prosthetic training. For regulatory context, most prostheses are FDA Class I devices exempt, while the DEKA (LUKE) Arm was cleared via a de novo 2014 process.

Evidence	Summary
ECRI MyoPro 2+ assessment (2024)
No published studies specifying MyoPro 2+ use; evidence insufficient
Hayes Utah Arm (2023)
Insufficient peer-reviewed literature for full assessment
Hayes myoelectric multigrip (2023)
No/unclear support in guidelines for multigrip hands
Hayes LUKE/DEKA (2021/2023)
Very low-quality evidence; inconsistent functional improvements

Definitions

Evidence limitations

Policy revision timeline

11/01/2025material addition (HCPCS codes added)Latest

Added HCPCS codes L6034, L6035, L6036, L6038, and L6039 to the list of applicable codes (quarterly edits reflected in updated applicable codes).

11/01/2025material revision (HCPCS descriptions revised)Latest

Revised descriptions for HCPCS codes L6028 and L7406 as part of the applicable codes quarterly update.

11/01/2025

Policy Summary

PayerUnitedHealthcare

PolicyUpper Extremity Prosthetic Devices (for New Mexico Only)

Policy CodePolicy N/A

Change TypeHCPCS codes added/revised (11/01/2025)

Effective DateNovember 1, 2025

Next Review Date

SourceLink

On This Page

Pre-prosthetic training should be ensured to determine appropriate device to achieve functional goals.
Expert Opinion
Required comprehensive assessment components: Comprehensive assessment components required: present health status; level of function; modifiable health risks; pain; cognition/behavioral health; personal/family/social/cultural context; learning assessment; residual limb assessment; non-amputated limb and trunk; prosthetic assessment; vocational assessment.
Prescription documentation requirements: Prescription must document device design (preparatory vs definitive), control strategy (passive, externally powered, body-powered, task-specific), anatomical side and amputation level, socket interface and frame, suspension mechanism, terminal device, and applicable wrist/elbow/shoulder units.

Pediatric considerations: Pediatric evidence shows mixed long-term preference; successful use in young children is possible with family support and training; many pediatric unilateral amputees end up selecting simpler devices or multiple prostheses based on function.

Outcome-measure limitations: Outcome measurement tools for upper-limb prosthesis users are limited; validated performance-based measures are sparse and may not fully capture functional restoration.

Study limitations common to device literature: Studies report benefits in specific measures (e.g., AM-ULA, SHAP, JTHFT) but are limited by small sample sizes, lack of randomization, heterogeneous devices, and variable training.

Suspension mechanism

Applicable wrist, elbow, and shoulder units

Documentation Required

Pre-prosthetic training and justification

Ensure and document pre‑prosthetic training and include documented training outcomes when requesting advanced or externally powered devices.

Billing Rule

Use updated HCPCS codes

Use the updated HCPCS codes for billing and note the 11/01/2025 policy update that added several codes and revised descriptions for two codes.

L6028
L6034
L6035
L6036
L6038
L6039
L7406
Effective update date: 11/01/2025 (codes added/revised)
Descriptions for L6028 and L7406 were revised

Supporting Information notes the previous policy version CS360NM.B was archived.