UnitedHealthcare Upper Extremity Prosthetics Coverage Update

Coverage Criteria

General medical necessity criteria

Covered when ALL of the following are met

General upper extremity prosthesis criteria: 1) Member has a traumatic or surgical amputation of upper extremity or a congenital absence or defect; 2) Prosthetic replaces all or part of a missing limb; 3) Prosthetic will help the member regain or maintain function; 4) Prosthetic device is ordered by or under the direction of a physician; 5) Prosthetic needs evaluated for member by a healthcare professional with appropriate prosthetic qualifications and training under the supervision of the ordering physician; 6) Member is willing and able to participate in training for use of the prosthetic; 7) Member with expected rehabilitation potential undergoes functional assessment including Activities of Daily Living (ADLs) and Instrumental ADLs (IADLs).

From Coverage Rationale.

Myoelectric prosthesis (below wrist)

Covered when ALL of the following are met

Myoelectric below-wrist criteria: 1) Member has a traumatic or surgical amputation below the wrist or a congenital missing or dysfunctional hand or finger; 2) Prosthetic replaces all or part of a missing limb; 3) Prosthetic will help the member regain or maintain function; 4) Prosthetic needs evaluated for member by a healthcare professional with appropriate prosthetic qualifications and training under the supervision of the ordering physician; 5) Member is willing and able to participate in training for use of the prosthetic; 6) Member is able to operate the stimulator of the computerized prosthetic or microprocessor; 7) Member with expected rehabilitation potential undergoes functional assessment including ADLs and IADLs; 8) Remaining musculature contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device (usually 3-5 muscle groups must be activated), no external switch; and ordering physician authorizes the final prosthetic proposal.minimum muscle groups: usually 3-5

Specific myoelectric criteria for below-wrist devices.

Myoelectric prosthesis (above wrist)

Refer to external criteria

Above-wrist myoelectric: Coverage for myoelectric prosthetic devices for amputations above the wrist is determined using the InterQual CP: Durable Medical Equipment, Prosthetics, Myoelectric, Upper Extremity, Above the Wrist (Custom) criteria referenced in the policy.

InterQual external reference per policy.

Bone-anchored percutaneous limb prosthesis

Not covered due to insufficient evidence

Bone anchored percutaneous limb prosthesis: Bone-anchored percutaneous limb prostheses (e.g., OPRA Implant System) are unproven and not medically necessary due to insufficient evidence of efficacy and high rates of infection and mechanical complications reported in studies.

Policy-level stance: unproven/not medically necessary.

Osseointegration — candidate selection

Consider osseointegrated upper‑limb prosthesis when ALL of the following apply

Osseointegration candidacy: Indication typically transhumeral or selected transradial amputations resulting from trauma or tumor with inability to use or severe problems using a conventional socket (for example, very short residual limb).

Document prior attempts with socket prosthesis and reasons for intolerance

Patient selection and counseling: Patient is willing to accept risks including skin‑penetration site infections and need for long‑term radiologic and clinical follow‑up; informed consent documented. Policy notes a 5‑year incidence of infectious complications and that use in vascular‑related amputations is untested/not recommended in cited series.

Discuss infection risk and limited evidence

Surgical plan: Two‑stage surgical approach documented (fixture insertion then staged abutment/skin‑penetrating component) and rehabilitation plan in place; include details of implant system and plan for monitoring bone remodeling and implant survivorship.

Include surgical staging and follow-up plan

Neuromusculoskeletal implanted‑electrode prosthesis — selection

Consider neuromusculoskeletal or implanted‑electrode myoelectric prosthesis when ALL of the following are met

Appropriate amputation level: Upper‑limb amputee (for example, transhumeral) with sufficient target muscles or documented nerve transfer to provide control signals for implanted electrodes.

Document nerve transfer or presence of native target muscles for electrode implantation

Device expectations: Patient counseled that device may provide intuitive control and graded sensory feedback; reported long‑term use is limited to small series and outcomes should be described realistically.

Document baseline function and realistic goals

Follow‑up capability: Ability and commitment to long‑term follow‑up documented for monitoring electrode impedance, prosthesis fitting, and management of infections or device complications.

Studies report early impedance increase then stabilization and potential for implant-related infections requiring management

Advanced myoelectric devices — assessment and training

When considering advanced myoelectric multi‑grip or powered wrists/hands

Evidence of functional benefit vs standard device: Evidence does not consistently demonstrate clear superiority of multi‑grip myoelectric hands or powered wrists/hands over standard single‑grip myoelectric or body‑powered devices; benefits vary by device and user and study limitations exist.

Consider trial and careful assessment due to mixed evidence and cost/repair burden

Training and rehabilitation: Structured training protocols and classifier/phase training should be planned and documented, as training can improve functional gains, selection accuracy, and user satisfaction.

Document training plan and user's prior prosthetic experience

Process requirements for prosthesis coverage

Covered when the following process-based conditions are met

Pre-prosthetic assessment: Patient underwent pre‑prosthetic training and a comprehensive assessment by the care team to determine appropriate device and functional goals.

Per VA/DoD pre‑prosthetic training recommendation

Collaborative prescription: Prescription documents design, control strategy, anatomical side and amputation level, socket interface and frame, suspension mechanism, terminal device, and applicable wrist/elbow/shoulder units as appropriate.

Collaborative decision‑making with patient and care team required

Bone-anchored percutaneous limb prostheses (for example, the OPRA Implant System) are classified in this policy as unproven and not medically necessary because the available evidence is limited in quality and reports high rates of infection and mechanical complications. Documentation in the cited literature notes concerns about implant survival and complication rates that prevent a determination of effectiveness and safety for routine coverage.

Osseointegrated arm prostheses have only been reported in selected series of transhumeral amputations due to trauma or tumor and have not been tested or recommended for transhumeral amputations resulting from vascular disease in the cited studies. The evidence is limited by small, retrospective cohorts, lack of comparative data with socket prostheses, and incomplete patient‑reported outcome measurement; these limitations inform the policy’s cautious stance and candidate‑selection requirements.

FDA clearance or marketing status is provided here for informational purposes only and is not a basis for coverage. Upper extremity prostheses are generally Class I devices and are exempt from routine FDA premarket review; the policy notes product codes (e.g., GXY, IQZ) and references the DEKA Arm de novo clearance (2014) as background information but does not equate clearance with medical necessity.

Osseointegrated (bone‑anchored) prostheses are considered unproven and not medically necessary due to insufficient evidence of long‑term safety and effectiveness, including substantial risks at the skin‑penetration site. For implanted or bone‑anchored systems that include myoelectric components, the policy emphasizes that myoelectric components for below‑wrist devices are only medically necessary when the specific myoelectric criteria (including adequate residual musculature and ability to operate the device) are met; otherwise, myoelectric components are considered not medically necessary.

Prescription of advanced multi‑grip myoelectric prostheses should be based on documented, individualized evidence of benefit for the member rather than on assumed superiority. Comparative studies and case series cited in the policy show mixed or inconclusive advantages of multi‑grip devices over standard single‑grip myoelectric or body‑powered prostheses; given higher cost and repair burden, the policy expects clear documentation of anticipated functional gains, training plans, and assessment outcomes to justify provision.

Coding and Billing

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, 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.
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	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.
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.

Sockets, additions, and terminal devicesHCPCS

L6680	Upper extremity addition, test socket, wrist disarticulation or below elbow.
L6682	Upper extremity addition, test socket, elbow disarticulation or above elbow.
L6686	Upper extremity addition, suction socket.
L6694	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism.
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).

Externally powered and related HCPCSHCPCS

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 locking hinges, forearm, electrodes, cables, two batteries and one charger, myoelectronic control of terminal device.
L6955	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, electrodes, cables, two batteries and one charger, myoelectric 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.
L7367	Lithium ion battery, rechargeable, replacement.

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Fee schedule notemixed

*	Codes marked with an asterisk (*) are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program.

inv-21: minimum muscle groups / microvolt threshold

Minimum muscle groupsUsually 3–5 residual muscle groups must be activated to operate a myoelectric computerized hand (minimum microvolt threshold)

Ability to operate microprocessor/stimulatorMember must be able to operate the stimulator of the computerized prosthetic or microprocessor (operator ability required)

No external switch allowedOperation must rely on myoelectric signals (no external switch permitted)

Provider Actions and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for osseointegrated (bone-anchored/percutaneous) prostheses and for upper-extremity myoelectric systems above the wrist. Submit prior authorization requests per UnitedHealthcare policy clinical criteria. InterQual® criteria may be referenced for myoelectric and above-wrist device determinations.

Prior authorization required for osseointegrated prostheses (bone-anchored/percutaneous)
InterQual® may be referenced for myoelectric and above-wrist device criteria

Documentation Required

Conservative Management Expectation

Osseointegration may only be considered when conservative management has been attempted and documented. Documentation should demonstrate trial and documented intolerance or inability to use a conventional socket prosthesis (e.g., very short residual limb, persistent severe socket-related pain, repeated inability to fit/retain a socket).

Document trial of conventional socket prosthesis and reasons for failure/intolerance

Background and Evidence Summary

Upper limb prostheses are categorized as passive, body‑powered, externally powered (myoelectric), or hybrid devices and are intended to restore or maintain function after transradial or transhumeral amputation. Myoelectric prostheses operate by battery‑powered motors activated via surface or implanted electrodes and require sufficient residual musculature and user training to achieve functional control; pre‑prosthetic assessment and rehabilitation planning are expected to determine appropriate device type and training needs.

Definitions

inv-35: Activities of Daily Living (ADLs)

DefinitionBasic tasks people need to do to function and interact such as bathing, grooming, dressing, toilet use, eating, and physical ambulation.

PurposeUsed in functional assessment to demonstrate prosthesis will help member regain or maintain function.

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

inv-36: Instrumental Activities of Daily Living (IADLs)

DefinitionHigher-order tasks related to independent living such as shopping, transportation, meal preparation, housecleaning, managing finances and managing medications.

Role in assessmentIncluded in functional assessment (IADLs) when determining prosthetic benefit and rehabilitation potential.

OpenPayer

Upper Extremity Prosthetic Devices (for Louisiana Only)

Coverage Criteria

Coding and Billing

Provider Actions and Documentation

Background and Evidence Summary

Definitions