DraftUnitedHealthcarePolicy CS360OH.D

Upper Extremity Prosthetic Devices (for Ohio Only)

Policy governing medical necessity, coverage, and coding for upper extremity prosthetic devices for members in Ohio; applies to ordering providers, prosthetists, and payers evaluating DME/prosthetic claims in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyUpper Extremity Prosthetic Devices (for Ohio Only)

Policy CodePolicy CS360OH.D

Change TypeHCPCS codes added/revised (material)

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization using the updated HCPCS L‑code list and document required clinical assessment and training readiness.

SourceLink

POLICY UPDATE CHANGES

Applicable HCPCS codes L6028, L6029, L6030, L6031, L6032, L6033, L6037, L6700, and L7406 were added.

Ohio-onlypolicy jurisdiction

Multiple L-codesHCPCS codes referenced

Presentmyoelectric below-wrist criteria

Unprovenosseointegration stance

83%/80% (2yr/5yr)implant survivorship

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Coverage and Medical Necessity Criteria

General upper extremity prosthesis (all levels)

Covered when ALL of the following are met

General upper extremity prosthesis medical necessity: Prosthetic replaces all or part of a missing limb; member has a traumatic or surgical amputation of the upper extremity or a congenital absence or defect; prosthetic will help the member regain or maintain function; prosthetic needs evaluation by a healthcare professional with appropriate prosthetic qualifications and training under the supervision of the ordering physician; prosthetic device is ordered by or under the direction of a physician; member is willing and able to participate in training for use of the prosthetic; member with expected rehabilitation potential undergoes functional assessment including Activities of Daily Living (ADLs) and Instrumental ADLs (IADLs)

Myoelectric prosthetic devices — below wrist

Myoelectric prosthetic below-wrist covered when ALL of the following are met

Myoelectric below-wrist criteria: Member has a traumatic or surgical amputation below the wrist or a congenital missing or dysfunctional hand or finger; prosthetic replaces all or part of the missing limb; prosthetic needs evaluation by a healthcare professional with appropriate prosthetic qualifications and training under the supervision of the ordering physician; prosthetic will help the member regain or maintain function; member is willing and able to participate in training for use of the prosthetic; member with expected rehabilitation potential undergoes functional assessment including ADLs and IADLs; member is able to operate the simulator of the computerized prosthetic or microprocessor; remaining musculature contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device (usually 3-5 muscle groups activated), with no external switch; ordering physician authorizes the final prosthetic proposalminimum EMG/muscle groups usually 3-5

See InterQual CP for above-wrist myoelectric criteria

Clinical coverage considerations

Coverage considerations and clinical selection cues reflected in the evidence (extract from studies):

Osseointegration candidate selection: Patient is typically a transhumeral (above-elbow) amputee with inability to wear or severe problems wearing a conventional socket prosthesis (e.g., very short residual limb) and is medically fit for surgery

Studies primarily included trauma or tumor-related amputations; vascular amputations were generally excluded or not recommended

Contraindications noted in literature: Absence of peripheral vascular disease, diabetes mellitus, and active residual limb infection are required for consideration of osseointegration

Sabharwal et al. excluded patients with vascular disease, diabetes, or residual limb infection

Expected outcomes and risks: Osseointegrated implants can provide improved suspension and function in selected patients but carry risks including skin-penetration-site infections (reported ~38% at 5 years), superficial and occasional deep infections, radiologic bone remodeling changes, and implant failures requiring removal in some cases

Implant survivorship reported as 83% at 2 years and 80% at 5 years (Tsikandylakis)

Assessment and Prescription Criteria

Clinical assessment and prescription requirements

Pre-prosthetic and prescription criteria: A comprehensive assessment by the care team must be performed including level of function; present health status; modifiable/controllable health risk factors; pain assessment; personal, family, social, and cultural context; cognition and behavioral health; learning assessment; residual limb assessment; non-amputated limb and trunk assessment; vocational assessment; and prosthetic assessment. Prescription decisions should be collaborative between patient and care team and the written prescription must specify device design (preparatory vs definitive), anatomical side and amputation level, control strategy, socket interface, suspension mechanism, socket frame, terminal device, and any applicable wrist, elbow, or shoulder units.

Expert opinion from VADoD 2022 guideline; document full component-level prescription and goals

Bone-anched percutaneous limb prostheses (for example, the OPRA Implant System) are considered unproven and not medically necessary in this policy. The available clinical evidence is limited and of low quality, and studies report high rates of infectious and mechanical complications that raise safety and efficacy concerns.

Use of osseointegrated arm prostheses is not recommended for routine coverage and has important patient-selection limits. Studies of osseointegration in transhumeral amputees have predominantly enrolled patients with trauma- or tumor-related amputations who could not tolerate conventional socket prostheses; patients with peripheral vascular disease, diabetes mellitus, or active residual limb infection were excluded from these series. Reported outcomes include implant survivorship but also substantial risks (including infectious complications and implant failures) that should be documented and considered during prior authorization and surgical candidacy evaluation.

FDA clearance or marketing authorization is provided for informational purposes only and is not a basis for coverage decisions. Most prosthetic devices are class devices exempt from U.S. Food and Drug Administration review; an FDA de novo clearance (for example, the DEKA/"LUKE" Arm System in 2014) does not by itself establish medical necessity for payment.

Myoelectric components for hands, partial-hands, and artificial digits below the wrist are considered not medically necessary when members do not meet the specific myoelectric device criteria. These criteria include documented below-wrist amputation or congenital absence, evaluation by an appropriately qualified prosthetics professional under physician supervision, demonstrated ability and willingness to participate in training, functional ADL/IADL assessment, ability to operate a computerized prosthetic simulator, meeting the minimum EMG/muscle activation threshold (typically 3–5 muscle groups), and ordering physician authorization of the final prosthetic proposal.

Current evidence does not clearly demonstrate that multi-grip myoelectric hands (MHPs) are superior to standard single-grip myoelectric hands (SHPs) for all patients. Comparative studies and single-case series report mixed results: some users show improved satisfaction or task performance with multi-grip devices, while others show no clear benefit and note higher cost and repair burden. Given the limited and heterogeneous evidence, prescribing an MHP should be individualized and justified in the medical record.

This section contains no additional explicit "not medically necessary" statements beyond those already specified elsewhere in the policy. When applying these policy statements, always verify and follow applicable federal, state (Ohio Administrative Code), or contractual benefit requirements, as those requirements govern coverage in the event of a conflict.

HCPCS / CPT / Regulatory Codes

Upper Limb Prosthetics (selected)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.

Upper extremity additions, sockets, myoelectric features, terminal devicesHCPCS

L6030	Upper extremity addition, test socket/interface, partial hand including fingers.
L6031	Upper extremity addition, external frame, partial hand including fingers.
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.
L6632	Upper extremity addition, latex suspension sleeve, each.
L6677	Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow.

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Complete list of myoelectric and accessory codesHCPCS

L6925	Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, electrodes, cables; two batteries and one charger, myoelectronic control of terminal device.
L6935	Below elbow, external power; self-suspended inner socket; removable forearm shell; electrodes, cables, two batteries and one charger, myoelectronic control of terminal device.
L6945	Elbow disarticulation, external power, molded inner socket; removable humeral shell, outside myoelectronic control of terminal device.
L6955	Forearm, 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, electrodes, cables, two batteries and one charger, myoelectronic control of terminal device.
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.

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No explicit codes in this document segmentmixed

No codes listed

Applicable HCPCS Codes Added/RevisedHCPCS

L6028	HCPCS code added (description revised in policy)
L6029	HCPCS code added (description revised in policy)
L6030	HCPCS code added (description revised in policy)
L6031	HCPCS code added (description revised in policy)
L6032	HCPCS code added (description revised in policy)
L6033	HCPCS code added (description revised in policy)
L6037	HCPCS code added (description revised in policy)
L6698	HCPCS code description revised
L6700	HCPCS code added (description revised in policy)
L7406	HCPCS code added (description revised in policy)

FDA product codes (informational)mixed

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

Minimum muscle groups activated (microvolt threshold)

Minimum activated muscle groupsUsually 3–5 discrete muscle groups with sufficient microvolt EMG signal are required to operate a computerized/myoelectric hand (minimum microvolt threshold) — no external switch

Context of requirementCriterion applies to myoelectric prosthetic devices for amputations below the wrist as part of medical necessity assessment

Assessment methodAbility to operate a computerized prosthetic simulator and demonstrable EMG signals from remaining musculature are required

Consequence if not metMyoelectric components for below-wrist devices are considered not medically necessary when minimum muscle/EMG thresholds are inadequate

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required per UnitedHealthcare rules for upper extremity prosthetic items and for many HCPCS L-codes listed in the Applicable Codes section. Prior authorization requests should use the current HCPCS codes on file and include device-specific clinical justification when applicable. Verify state and contractual requirements before submission.

Prior authorization required for upper extremity prosthetic items and many HCPCS L-codes
Use current HCPCS codes when requesting prior authorization — verify state/contractual rules
Include device-specific clinical rationale for advanced components (e.g., myoelectric, osseointegration)

Prior Authorization

Advanced Prosthesis / Osseointegration Prior Authorization

For advanced prosthetic approaches including osseointegration (bone-anchored percutaneous limb prostheses) and other surgical/procedural prosthetic interventions, prior authorization must document prior conservative prosthetic management (e.g., inability to tolerate or failure of conventional socket prosthesis), explicit surgical candidacy criteria, and patient selection rationale. Include evidence of exclusion of contraindications (for example, uncontrolled infection, uncontrolled diabetes, peripheral vascular disease when applicable) and documentation of informed consent discussing infection and device survivorship risks.

Background and Evidence Summary

Upper limb prostheses are designed to replace all or part of a missing upper extremity to restore function. Common amputation levels relevant to this policy include transradial (below-elbow) and transhumeral (above-elbow). Prostheses are classified as passive (cosmetic), body-powered, hybrid, or externally powered (myoelectric), and device selection should be based on clinical assessment, rehabilitation potential, and patient goals.

Key Terms and Definitions

Myoelectric Prosthetic — definition and operational note

DefinitionA prosthetic device powered by battery-driven electric motors and controlled by electrodes that detect muscle myoelectric potentials (EMG)

Typical componentsBattery(s), motorized terminal device, electrodes and cables, microprocessor control or myoelectronic control module

Operational noteMember must be able to operate a computerized prosthetic simulator and have sufficient residual musculature EMG to drive the device

ADLs / IADLs — definitions

ADLs (Activities of Daily Living)Basic self-care tasks such as bathing, grooming, dressing, toileting, eating, and ambulation

IADLs (Instrumental ADLs)More complex activities needed for independent living such as shopping, transportation, meal preparation, housecleaning, managing finances, and managing medications

Policy Summary

PayerUnitedHealthcare

PolicyUpper Extremity Prosthetic Devices (for Ohio Only)

Policy CodePolicy CS360OH.D

Change TypeHCPCS codes added/revised (material)

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization using the updated HCPCS L‑code list and document required clinical assessment and training readiness.

SourceLink

On This Page

Evidence for neuromusculoskeletal/robotic interfaces: Small case series (n=4) report long-term (3–7 years) functional control and sensory feedback using implanted electrodes with osseointegrated fixation, suggesting improved prosthesis trust and activity participation but requiring larger comparative studies

Ortiz-Catalan et al. results are promising but limited by small sample size

Myoelectric and multi-grip devices: Evidence is mixed: some studies show improved task performance or patient satisfaction with powered wrists or multi-grip hands, while others do not demonstrate clear superiority over standard myoelectric hands; training, durability, and cost/repair considerations are important

Kerver, Olsen, Widehammar and other assessments report variable outcomes

Document prior conservative management and reasons for osseointegration candidacy (e.g., severe socket intolerance, very short residual limb)
Document surgical candidacy: absence of active infection at residual limb, medical optimization, and ability to comply with follow-up
Include informed consent addressing infection risk and implant survivorship statistics

Billing Rule

Applicable Codes Added — Prior Authorization Implication

Applicable HCPCS codes have been added or revised and must be used for prior authorization and billing. Inclusion of a code in the policy is for reference and does not guarantee coverage; coverage is governed by federal, state (OAC), or contractual requirements.

New/revised HCPCS codes added: L6028, L6029, L6030, L6031, L6032, L6033, L6037, L6700, L7406; revised description for L6698
Verify state and contractual coverage requirements before billing

Denial Risk

Claims May Be Denied if Device Is Not Ordered by or Under Direction of a Physician or Member Cannot Participate

Claims may be denied if the device is not ordered by or under the direction of a physician, or if the member is unwilling or unable to participate in required training and rehabilitation. Ensure the ordering provider and documentation meet plan requirements.

Device must be ordered by or under the direction of a physician
Document member willingness and ability to participate in training and rehabilitation

Denial Risk

Myoelectric Prosthetic Components — Denial Risk When Criteria Not Met

Myoelectric prosthetic components for below‑wrist devices are medically necessary only when specific criteria are met (see InterQual criteria and policy clinical criteria). If criteria are not documented — including ability to operate the device simulator and adequate residual musculature and myoelectric signal thresholds — components may be considered not medically necessary and denied.

Document ability to operate computerized prosthetic simulator (below-wrist devices)
Document adequate myoelectric signal (minimum microvolt thresholds and muscle group activation)
If criteria not met, myoelectric components for below‑wrist prostheses are not medically necessary

Denial Risk

Osseointegration Infection and Survivorship Risks

Osseointegration (bone‑anchored percutaneous limb prostheses) carries substantial infection and device survivorship risks. Prior authorization and informed consent should address rates of superficial and deep infections and reported implant survival statistics.

Report and discuss infection risks related to skin penetration site (multiple superficial infections reported)
Document implant survival statistics and potential need for implant removal or revision
Ensure patients understand long‑term follow‑up and potential complications

Note

State / Contractual Requirement Conflict Risk

Benefit coverage is governed by federal, state (Ohio Administrative Code), and contractual requirements. In the event of conflict between this policy and applicable federal/state/contractual rules, the federal/state/contractual requirements control. Verify OAC and contract terms when applying this policy.

Follow federal, state (OAC), and contractual rules where they differ from this policy
Verify Ohio Administrative Code provisions, DMEPOS rules, and repair/coverage limits prior to authorization or billing

Documentation Required

Required Documentation Includes Evidence of Amputation, Functional Assessment, and Prescription Details

Required documentation for prior authorization and claims must include evidence of the amputation or congenital absence/defect, a comprehensive functional assessment (including ADLs and IADLs), a detailed prosthetic prescription, and documentation of the prosthetist evaluation and the ordering physician's authorization.

Evidence of amputation or congenital absence/defect (operative report, clinic note, imaging)
Functional assessment including ADLs and IADLs and rehabilitation potential
Prosthetist evaluation notes and prosthetic needs assessment
Detailed prescription specifying device design, control strategy, socket type, suspension, terminal device, and all components
Ordering physician authorization of final prosthetic proposal

Documentation Required

Required Clinical Documentation for Advanced / Procedural Prosthetic Approaches

For advanced or procedural prosthetic approaches (e.g., osseointegration, neuromusculoskeletal interfaces), required clinical documentation should include prior intolerance or failure of conventional socket prostheses, cause of amputation, medical comorbidities that affect candidacy, infection status, and documentation that the member meets defined surgical and rehabilitative criteria.

Document prior conservative management and reasons for considering advanced approach (e.g., severe socket problems)
Specify cause and level of amputation (trauma, tumor, congenital)
List comorbidities (diabetes, vascular disease, infection) and their management
Confirm infection-free residual limb and medical optimization for surgery

Documentation Required

Required Assessment and Prescription Documentation

Required assessment and prescription documentation should be comprehensive and multidisciplinary: include level of function, pain assessment, cognition/behavioral health, residual‑limb and contralateral limb assessment, vocational/learning assessment, and a complete prosthesis prescription (design, components, control strategy, socket and suspension details).

Assessment components: level of function, present health status, modifiable risk factors, pain, cognition, learning ability, residual limb and contralateral limb assessment, vocational assessment
Prescription must include: device design (preparatory vs definitive), anatomical side and amputation level, control strategy, socket interface, suspension mechanism, socket frame, terminal device, wrist/elbow/shoulder units if applicable

Note

Policy References Ohio Administrative Code and DMEPOS Provisions

This policy references the Ohio Administrative Code (OAC) provisions related to DMEPOS (including repair rules) and other state requirements. Providers must follow OAC Rule 5160-10-02 and related DMEPOS rules where applicable.

Ohio Administrative Code Rule 5160-10-02 DMEPOS referenced for repair and coverage limits
Follow OAC and DMEPOS provisions when preparing authorizations and claims

Step Therapy

Conservative Management Before Advanced Prostheses

Conservative management must be documented before considering advanced prosthetic options. Select patients for advanced devices only after documented failure or inability to tolerate conventional socket prostheses.

Document attempts with conventional socket prostheses and reasons for failure/intolerance
Conservative management documentation is required in prior authorization for osseointegration or other advanced devices

Note

Clinical Criteria Source / Step

UnitedHealthcare uses InterQual for primary medical/surgical criteria for prosthetics. If InterQual does not have applicable criteria, UnitedHealthcare may use its Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines (as approved by the Ohio Department for Medicaid Services). Include InterQual criteria references in prior authorization submissions when available.

Primary clinical criteria source: InterQual (Durable Medical Equipment; Prosthetics, Myoelectric, Upper Extremity)
If InterQual is not applicable, UnitedHealthcare Medical Policies/Coverage Determination Guidelines/Utilization Review Guidelines may be used as fallback (per Ohio Department for Medicaid Services)

Use in policyFunctional assessment for prosthetic candidacy must include evaluation of ADLs and IADLs

Prosthesis classification

Passive prosthesisLightweight, often cosmetic; no motors and limited mechanical features

Body-powered prosthesisOperated via body movements using a harness and cable system (durable, lightweight; requires harness and user strength)

Hybrid prosthesisCombines body-powered and externally powered components; used often for high-level amputees

Externally powered prosthesisBattery-powered systems controlled by EMG, force sensors or switches (provides more force; requires charging and maintenance)

Neuromusculoskeletal interface

DefinitionAn implanted system combining osseointegration (bone-anchored fixation) with electrodes implanted in muscles and/or nerves to enable bidirectional motor control and sensory feedback between the prosthesis and the user's nervous system

ComponentsOsseointegrated implant anchored to bone plus epimysial or neural electrodes connected to the prosthetic device

Clinical noteReported in small case series enabling intuitive control and sensory percepts; requires surgical nerve transfers or electrode implantation

Multi-grip myoelectric prosthesis (MHP) — definition

DefinitionAn externally powered myoelectric hand offering multiple programmable grip patterns (multiple articulating digit grasps) compared with standard single-grip myoelectric hands

Clinical considerationsEvidence is mixed regarding superiority over standard myoelectric hands; cost, durability, and training requirements should be evaluated

Control requirementsCan be operated with multi-site EMG or pattern-recognition control and may require structured training or simulator use

Dual-window pattern recognition classifier — definition and purpose

DefinitionA pattern-recognition classifier that switches between long and short EMG analysis windows to improve control of partial-hand prostheses, reducing classification error and task completion time

PurposeDesigned to combine different EMG window lengths and techniques (e.g., majority voting, classification delay) to lower misclassification and speed grasp selections

EvidenceStudies show reduced classification error and improved real-time task completion and selection metrics when using dual-window or similar techniques

Prostheses device regulatory status

Regulatory status—generalMost prostheses are class devices exempt from FDA review; FDA clearance alone is not a basis for coverage (informational)

DEKA Arm System noteThe DEKA (LUKE) Arm System received FDA de novo 513(f)(2) clearance in 2014 (informational)

Product codes (informational)FDA product codes referenced in policy include GXY and IQZ