UnitedHealthcare upper-extremity prosthetics Coverage Update

Coverage and Medical Necessity Criteria

inv-01: General medical necessity for upper extremity prosthesis — Covered when ALL of the following are met:

Covered when ALL of the following are met:

Primary coverage criteria for upper extremity prosthesis: Member has a traumatic or surgical amputation of the upper extremity or a congenital absence or defect; and prosthetic replaces all or part of a missing limb; and the prosthetic will help the member regain or maintain function; and the prosthetic device is ordered by or under the direction of a physician; and prosthetic needs are evaluated for the member by a healthcare professional with appropriate prosthetic qualifications and training under the supervision of the ordering physician; and the member is willing and able to participate in training for use of the prosthetic; and the member with expected rehabilitation potential undergoes a functional assessment including activities of daily living (ADLs) and instrumental ADLs (IADLs).

From Coverage Rationale.

inv-02: Myoelectric prosthesis (below wrist) — covered criteria; additional ALL requirements

Myoelectric prosthesis — below-wrist additional requirements (ALL):

Myoelectric (below wrist) specific criteria: 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 the missing limb; and the prosthetic will help the member regain or maintain function; and prosthetic needs are evaluated for the member by a healthcare professional with appropriate prosthetic qualifications and training under the supervision of the ordering physician; and the member is willing and able to participate in training for use of the prosthetic; and the member is able to operate the stimulator of the computerized prosthetic or microprocessor; and the member with expected rehabilitation potential undergoes functional assessment including ADLs and IADLs; and the remaining musculature of the arm contains the minimum microvolt threshold to allow operation of a Myoelectric Prosthetic device (usually 3-5 muscle groups must be activated) without an external switch; and the ordering physician authorizes the final prosthetic proposal.minimum microvolt threshold; usually 3-5 muscle groups

Myoelectric below-wrist criteria.

inv-03: Myoelectric prosthesis (above wrist) — referenced criteria (InterQual referenced)

Myoelectric prosthesis — above-wrist:

Myoelectric (above wrist) coverage reference: Myoelectric prosthetic devices for amputations above the wrist are medically necessary in certain circumstances; medical necessity clinical coverage criteria for above-wrist myoelectric upper-extremity prostheses are referenced to InterQual CP: Durable Medical Equipment, Prosthetics, Myoelectric, Upper Extremity, Above the Wrist (Custom) - UHG.

Provider must refer to InterQual criteria for above-wrist cases.

inv-04: Osseointegrated upper-extremity prosthesis — study-based coverage considerations; evidence summaries and cohort descriptions

Evidence summaries and cohort descriptions indicate use and patient selection observed in studies; coverage considerations should reflect these study populations and reported outcomes.

Osseointegration candidate characteristics: Patient has a transhumeral or other upper-limb amputation resulting from trauma or tumor; has inability to wear or severe problems with a conventional socket prosthesis (for example, very short residual limb); and is a compliant candidate for the two-stage surgical procedure described in the literature (fixture implantation followed by skin-penetrating abutment).

Based on study inclusion criteria and authors' reported typical indications

Exclusion/contraindications observed in studies: Patient does NOT have peripheral vascular disease, diabetes mellitus, or active infection of the residual limb, as these comorbidities were excluded in cited prospective cohorts and may contraindicate consideration of osseointegration.

Presence of these comorbidities was exclusionary in at least one prospective cohort

Evidence for benefit and risk: Small prospective and retrospective studies report improved control, activities, and patient-reported outcomes in selected patients, but overall evidence is limited and comparative data are lacking; notable risks include skin‑penetration site infections and other complications (implant survivorship reported ~83% at 2 years and ~80% at 5 years; infection incidence ~38% at 5 years).

inv-05: Myoelectric and multi-grip devices — study-based coverage considerations; mixed evidence, small studies, limited comparative data

Evidence for myoelectric, multi-grip hands, and powered wrists is mixed, with small studies and limited comparative data.

Myoelectric/multi-grip outcomes: Some small studies report improved task performance, reduced compensatory movements, or increased user satisfaction with powered wrists or multi-grip hands in selected participants, while other comparative studies found no clear benefit of multi-grip over single-grip prostheses; overall evidence quality is low to very low and comparative data are limited.

Includes small cross-over studies, case series, HTA and evidence assessments noting insufficient quantity and quality of studies

Clinical uncertainty and need for training: Studies note the importance of structured training and that device features may not translate to real-world use; clinicians should consider training needs, repair/maintenance burden, and cost when prescribing multi-grip or powered components.

Cited limitations include small samples, lack of randomization, and heterogeneity

inv-06: Assessment and Prescription Criteria — comprehensive assessment and collaborative decision-making process

Coverage and prescription should follow a comprehensive assessment and collaborative decision-making process

Pre-prosthetic and prescription process: Care team must perform pre-prosthetic training and a comprehensive assessment prior to prosthesis prescription, including present health status, level of function, modifiable health risks, pain, cognition/behavioral health, psychosocial context, learning ability, residual limb assessment, non-amputated limb and trunk assessment, prosthetic assessment, and vocational assessment.

VA/DoD Clinical Practice Guideline recommended components

Prescription components: Prescription must document device design (preparatory vs definitive), control strategy, anatomical side and amputation level, socket interface and frame, suspension mechanism, terminal device, and applicable joints (wrist/elbow/shoulder).

Collaborative decision between patient and care team

Documentation requirement: The patient's medical record must contain documentation that fully supports the medical necessity for the requested services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; records must be legible and made available upon request.

Bone-anchored percutaneous limb prostheses (for example, the OPRA Implant System) are considered unproven and not medically necessary. The policy finds the available clinical evidence insufficient to conclude that these devices are effective and safe because published studies are few, of limited quality, and report relatively high rates of infectious and mechanical complications. As a result, osseointegrated percutaneous prostheses are not covered outside of clearly documented investigational settings or clinical trials.

Reported use of osseointegrated arm prostheses in the literature has been limited to patients with amputations resulting from trauma or tumor and typically enrolled individuals who had significant problems tolerating conventional socket prostheses (for example, very short residual limbs). Studies describe a two-stage surgical pathway and select for compliant candidates without peripheral vascular disease, diabetes mellitus, or active residual limb infection. Given the limited, noncomparative evidence and notable complication profile, policy coverage, prior-authorization review, and documentation expectations should reflect these usage contexts and the restricted populations in which the technique has been studied.

FDA regulatory status for prosthetic devices is provided for informational purposes only and FDA approval or clearance alone is not a basis for coverage. Prostheses are generally class I devices exempt from routine FDA review; specific device clearances (for example, the DEKA Arm System de novo clearance) do not by themselves establish medical necessity under this policy.

Myoelectric prosthetic components for hands, partial-hands, and artificial digits below the wrist are considered not medically necessary when the patient does not meet the stated device-specific criteria. Covered below-wrist myoelectric devices require that the member have an appropriate amputation or congenital absence, that the prosthesis will help regain or maintain function, that evaluation and training by qualified prosthetic professionals occur under physician direction, and that the residual musculature meets minimum electromyographic thresholds (typically activation of ~3–5 muscle groups) to operate the device without external switching.

For several newer or less well-studied powered upper-limb systems (for example, publications assessing the Utah Arm and MyoPro 2+), evidence is currently insufficient to demonstrate consistent clinical benefit. Systematic and technology-assessment reviews conclude the quantity and quality of published data are limited, so the clinical usefulness of these specific devices for the stated indications remains unproven and is not established as standard medical practice.

HCPCS / CPT / Regulatory Codes

Upper Limb Prosthetics (partial list)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.
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 MCP, PIP, and/or 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 MCP, IP joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement.

Upper Limb Prosthetics (continued)HCPCS

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, 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.
L6629	Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal.
L6632	Upper extremity addition, latex suspension sleeve, each.
L6677	Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow.
L6680	Upper extremity addition, test socket, wrist disarticulation or below elbow.
L6682	Upper extremity addition, test socket, elbow disarticulation or above elbow.

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Upper Limb Prosthetics (additional codes)HCPCS

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.
L6935	Below elbow, 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.
L6945	Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device.
L6955	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectric control of terminal device.
L6975	Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal 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.

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Applicable HCPCS codes (updated)HCPCS

L6034	Added HCPCS code
L6035	Added HCPCS code
L6036	Added HCPCS code
L6038	Added HCPCS code
L6039	Added HCPCS code
L6028	Description revised
L7406	Description revised

FDA product codes (informational)mixed

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

Myoelectric muscle groups / microvolt threshold — operational requirements

Required activated muscle groupsUsually 3-5 residual muscle groups must be activatable to operate a myoelectric (computerized) hand without an external switch.

Minimum microvolt thresholdRemaining musculature must contain the minimum microvolt threshold (documented in evaluation) to allow operation of the device.

Device control capabilityMember must be able to operate the stimulator of the computerized prosthetic or microprocessor as part of candidacy.

Evaluation requirementProsthetic needs must be evaluated by a healthcare professional with appropriate prosthetic qualifications and training under physician supervision to confirm muscle signal adequacy.

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required per plan rules for osseointegration (bone-anchored percutaneous limb prostheses) and for upper extremity prosthetic devices. Requests for osseointegration must include documentation demonstrating that the member has tried and had inadequate tolerance or function with a conventional socket prosthesis when applicable, and that the member meets the clinical selection criteria and has no contraindicating comorbidities documented (see items). Requests may be denied if the member does not meet medical necessity criteria or required documentation is incomplete.

Prior authorization required for osseointegration procedures and upper extremity prosthetic devices per plan rules; include preauthorization reference number when submitting claims.
Include documentation that member has attempted and been unable to tolerate an appropriate socket prosthesis when a socket trial is clinically feasible (trial of socket prosthesis prior to osseointegration is implied by study selection and surgical pathways).
Provide clinical rationale and supporting records for osseointegration including indication (e.g., inability to wear or severe problems wearing a conventional socket such as very short residual limb), expected rehabilitation potential, and justification for choosing osseointegration over conventional prosthesis.
List of updated HCPCS codes must be used for billing; documentation must support medical necessity for each billed code (see Applicable Codes section for most recent code updates).
Attach operative reports describing the staged surgical pathway for osseointegration (fixture insertion and later abutment attachment), rehabilitation plan, and evidence of informed consent discussing risks including infection and implant failure.

Clinical Background and Evidence Context

Upper limb prostheses replace part or all of a missing limb and are intended to restore function across common amputation levels such as transradial (below-elbow) and transhumeral (above-elbow). Devices are categorized as passive (cosmetic), body-powered, externally powered (myoelectric), and hybrid systems; selection should be individualized based on the level of amputation, functional goals (including Activities of Daily Living and Instrumental ADLs), residual limb status, patient willingness and ability to train, and the supervising clinician’s assessment.

Definitions and Terms

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.

Assessment roleADL evaluation is required as part of functional assessment for prosthesis candidacy (included in myoelectric below-wrist criteria).

ExamplesExamples include bathing, grooming, dressing, toileting, eating, and ambulation.

Instrumental Activities of Daily Living (IADLs)

DefinitionHigher cognitive and complex activities related to independent living such as shopping, transportation, meal preparation, housecleaning, managing finances, and managing medications.

Assessment roleIADL evaluation is required as part of functional assessment for prosthesis candidacy (included in myoelectric below-wrist criteria).

OpenPayer

Upper Extremity Prosthetic Devices (for Nebraska Only)

Coverage and Medical Necessity Criteria

HCPCS / CPT / Regulatory Codes

Prior Authorization, Documentation, and Denial Risks

Clinical Background and Evidence Context

Definitions and Terms