ModifiedUnitedHealthcarePolicy CS360PA.D

Upper Extremity Prosthetic Devices (for Pennsylvania Only)

Medical necessity, coverage, and coding guidance for upper extremity prosthetic devices for UnitedHealthcare Pennsylvania plans, including myoelectric devices and bone-anchored prostheses; references InterQual criteria for certain myoelectric devices.

Policy Summary

PayerUnitedHealthcare

PolicyUpper Extremity Prosthetic Devices (for Pennsylvania Only)

Policy CodePolicy CS360PA.D

Change TypeApplicable HCPCS codes added and descriptions revised

Effective DateFeb 1, 2026

Next Review Date

Key ActionVerify member benefits and obtain any required prior authorization before device provision.

SourceLink

POLICY UPDATE CHANGES

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

Revised descriptions for HCPCS codes L6028 and L7406.

Archived previous policy version CS360PA.C.

PAapplies to (state)

>=3-5min muscle groups

38%5‑yr infection rate

8osseo studies

76%

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pediatric success rate

Coverage Criteria for Upper Extremity Prostheses

inv-01: Upper extremity prosthesis — general — Covered when ALL of the following are met

Covered when ALL of the following are met:

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

inv-02: Myoelectric prosthesis (above wrist) — Covered when criteria per InterQual are met

Covered when criteria per InterQual are met:

Myoelectric prosthesis above wrist: An upper extremity myoelectric prosthetic for amputations above the wrist is proven and medically necessary in certain circumstances; medical necessity clinical coverage criteria reference InterQual Durable Medical Equipment, Prosthetics, Myoelectric, Upper Extremity, Above the Wrist (Custom) - UHG.

inv-03: Myoelectric prosthesis (below wrist) — Covered when ALL of the following are met

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 missing limb; prosthetic will help regain or maintain function; prosthetic needs evaluated by qualified prosthetic professional under supervision of ordering physician; member is willing and able to participate in training; member is able to operate the stimulator of the computerized prosthetic or microprocessor; remaining musculature contains the minimum microvolt threshold to allow operation (usually 3-5 muscle groups); ordering physician authorizes the final prosthetic proposal.

inv-04: Osseointegrated upper-limb prosthesis: evidence synopsis — Evidence-based context and commonly reported selection features from the literature

Evidence-based context and commonly reported selection features from the literature:

Typical candidate features for osseointegration in reports: Transhumeral amputations due to trauma or tumor, difficulty or inability to wear conventional socket prosthesis (e.g., very short residual limb), and motivated/compliant patients; vascular-cause amputations were not studied and are not recommended in the cited series.

Reported benefits in small studies: Improved prosthetic function, intuitive control with implanted electrodes, reduced phantom limb pain in some cases, and increased user satisfaction and activity participation.

Reported harms/limitations: High rates of skin-penetration site infections (reported 38% at 5 years in one series), device failures requiring removal, and radiologic bone changes of uncertain long-term significance; available studies are small, retrospective, and lack comparative data.

inv-05: Myoelectric and multi-grip prostheses: evidence synopsis — Key findings about externally powered myoelectric and multi-grip devices

Key findings about externally powered myoelectric and multi-grip devices:

Functional impact: Studies report mixed or limited benefits; some small studies show improved task performance with powered wrists or multi-grip hands, while other studies show no clear advantage of multi-grip devices over standard single-grip myoelectric hands.

Training and usability: Structured training and improvements in classifier/control strategies can reduce classification error and improve function; patient training and prior experience influence outcomes.

Guidance from assessments: Technology assessments and systematic reviews conclude the evidence is low quality and insufficient for definitive comparative recommendations; careful prescription is advised given device cost and repair burden.

inv-06: Prescription and Pre-Prosthetic Training — Covered when device prescription follows a comprehensive assessment and collaborative decision-making process

Covered when device prescription follows a comprehensive assessment and collaborative decision-making process:

Pre-prosthetic and prescription criteria: Care team conducts pre-prosthetic training and a comprehensive assessment (present health status, level of function, modifiable risk factors, pain, cognition/behavioral health, psychosocial context, learning ability, residual limb assessment, non-amputated limb/trunk assessment, prosthetic assessment, and vocational assessment) AND care team writes a prescription specifying device design, control strategy, anatomic side/level, socket interface/frame, suspension mechanism, terminal device, and any wrist/elbow/shoulder units.

Bone-anchored percutaneous limb prostheses (osseointegrated systems such as the OPRA Implant System) are considered unproven and not medically necessary for provision as an upper-extremity prosthesis. The policy reflects that the available clinical evidence is limited in quantity and quality and reports high rates of infectious and mechanical complications, such that efficacy and safety have not been established.

Clinical reports identify substantial risks—including implant failures and skin‑penetration site infections—that undermine confidence in routine use of these devices compared with conventional socket prostheses. Given the current evidence gaps, osseointegrated bone‑anchored prostheses remain investigational for general coverage determinations.

For transhumeral (above‑elbow) amputations attributable to vascular disease, use of osseointegrated arm prostheses is not recommended based on the available literature. Published series to date have included patients with trauma or tumor etiologies and did not evaluate outcomes after vascular‑related amputation; therefore safety and effectiveness in that population have not been established and routine use should be avoided.

FDA status is provided for informational purposes only. FDA approval or device classification alone is not a basis for coverage; many prostheses are Class I devices exempt from premarket review. Coverage decisions must be made according to the plan’s benefit terms and the clinical evidence rather than FDA clearance status alone.

Myoelectric prosthetic components intended for hands, partial hands, or individual digits below the wrist are considered not medically necessary when the member does not meet the specified eligibility criteria. These criteria include adequate residual musculature and microvolt signal thresholds (typically activation of 3–5 muscle groups), demonstrated ability to operate the device or stimulator, and completion of required evaluations and training under qualified prosthetic professionals.

The evidence regarding advanced externally powered devices (for example, some multi‑grip hands, prototype neuromusculoskeletal interfaces, and novel externally powered arms) is limited by small sample sizes, low‑quality study designs, and short or inconsistent follow‑up. Systematic reviews and technology assessments conclude that the current body of literature is insufficient to demonstrate consistent clinical superiority or broad applicability, so conclusions about effectiveness remain uncertain.

This Medical Policy is informational and must be applied in the context of the member’s specific benefit plan and any applicable federal or state requirements. Contractual, state, or federal terms govern if they conflict with this policy; always verify benefits and applicable coverage rules before proceeding.

Applicable Codes and Coding Notes

Applicable HCPCS L-codesHCPCS

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.

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Applicable HCPCS Codes (updated)HCPCS

L6034	Applicable HCPCS code added (description revised in policy update)
L6035	Applicable HCPCS code added (description revised in policy update)
L6036	Applicable HCPCS code added (description revised in policy update)
L6038	Applicable HCPCS code added (description revised in policy update)
L6039	Applicable HCPCS code added (description revised in policy update)
L6028	HCPCS code description revised
L7406	HCPCS code description revised

Minimum residual muscle groups — myoelectric hand

Minimum residual muscle groupsUsually 3–5 residual muscle groups must be activated to allow operation of a computerized/myoelectric hand (minimum microvolt threshold required).

Required musculature assessmentRemaining musculature must be evaluated for sufficient myoelectric signal (microvolt threshold) by qualified prosthetic clinician.

No external switch optionOperation expectation is for direct myoelectric control (no external switch) when the 3–5 muscle-group threshold is met.

Pediatric successful-use definition

Pediatric successful-use definition> 2 hours per day wearing the myoelectric device defines successful use in the referenced preschool study (Egermann et al., 2009).

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Considerations for Osseointegration

Prior authorization is required for osseointegration (bone-anchored percutaneous limb prostheses). Prior authorization decisions must consider the limited cohort evidence for osseointegration, including implant survival, high incidence of infectious complications related to the skin-penetration site, and uncertain long-term radiologic findings. Requests should document the clinical rationale for osseointegration (e.g., inability to use a conventional socket prosthesis such as very short residual limb or severe socket intolerance) and reference that osseointegration has primarily been reported in traumatic or tumor etiologies, with limited evidence in vascular amputations.

Osseointegration prior auth required
Document prior conventional socket issues and specific rationale for osseointegration
Include evidence of rehabilitation potential and patient/caregiver willingness

Prior Authorization

Verify Benefits and Obtain Prior Authorization

Verify member benefits and applicable federal, state, or contractual requirements prior to ordering. Obtain any required prior authorization from UnitedHealthcare before procurement or surgery. Coverage determinations must follow the member's specific plan terms and any applicable jurisdictional mandates.

Definitions

Activities of Daily Living (ADLs)

DefinitionBasic tasks people need to do to function and interact, e.g., bathing, grooming, dressing, toilet use, eating, and ambulation.

PurposeUsed to assess functional potential and rehabilitation needs prior to prosthesis prescription.

Assessment contextIncluded in pre-prosthetic functional assessment requirements to document expected rehabilitation potential.

Instrumental Activities of Daily Living (IADLs)

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

PurposeUsed alongside ADLs to evaluate functional independence and device candidacy.

Background

Upper‑limb prostheses restore function after loss of an arm or hand and are commonly prescribed for amputations at the transradial (below‑elbow) and transhumeral (above‑elbow) levels. Devices range from passive (cosmetic) and body‑powered systems to externally powered/myoelectric and hybrid designs; selection should be guided by amputation level, residual limb characteristics, functional goals, and the user’s ability to generate control signals.

Myoelectric systems require adequate residual musculature and training to operate (typically 3–5 muscle groups are needed for computerized hands), and clinical assessment should include ADLs and IADLs to determine expected rehabilitation potential and appropriate device prescription.

Revision History and Policy Changes

2026-02-01codes_updatedLatest

Quarterly applicable codes update: added HCPCS codes L6034, L6035, L6036, L6038, and L6039 and revised descriptions for L6028 and L7406; archived prior policy version CS360PA.C.

Policy Summary

PayerUnitedHealthcare

PolicyUpper Extremity Prosthetic Devices (for Pennsylvania Only)

Policy CodePolicy CS360PA.D

Change TypeApplicable HCPCS codes added and descriptions revised

Effective DateFeb 1, 2026

Next Review Date

Key ActionVerify member benefits and obtain any required prior authorization before device provision.

SourceLink

On This Page

Observed successful-use rate

76% of children in the study met the >2 hours/day successful-use threshold over two years.

Mean daily wear time in successful usersMean reported daily use among successful pediatric users was 5.8 ± 4.1 hours/day.

Check benefits for prosthetic coverage and any state/federal mandates
Obtain UnitedHealthcare prior authorization when required before device provision or surgery
If contract or law conflicts with this policy, the federal/state/contract requirements govern

Denial Risk

Infection and Device Survival Risks

Osseointegration carries substantial risks of infectious complications at the skin-penetration site, notable rates of skin reactions, and implant failures in published series. Implant survival in available small cohorts is variable (reported ~80–83% at 2–5 years) and infectious complication rates have been reported up to approximately 38% at 5 years. These risks should be clearly discussed and documented in the clinical record and informed consent.

Reported implant survival ~80–83% at 2–5 years
Five-year infectious complication incidence reported up to ~38%
Most infections were managed nonoperatively but deep implant infection and implant removal have occurred

Note

Conflicting Contractual/State Requirements

When federal, state, or contractual requirements differ from this policy, those requirements prevail. Prior authorization and coverage decisions must adhere to the member's specific plan language and any applicable laws.

Follow federal/state/contract terms when conflicts exist
Policy is informational; check member contract and jurisdictional mandates before final determination

Documentation Required

Required Documentation for Medical Necessity

To substantiate medical necessity for upper extremity prosthetic devices (including consideration of osseointegration), submit documentation that clearly demonstrates the amputation or congenital absence, the functional deficits the prosthesis will address, and evidence that the prosthesis is expected to restore or maintain function. Include documentation of prosthetic evaluation and the prescribing clinician’s involvement.

Diagnosis and operative report or documentation of congenital absence
Statement of functional deficits and goals addressed by the prosthesis
Evidence prosthetic will help regain or maintain function
Ordering physician's authorization and involvement in the plan of care

Documentation Required

Suggested Clinical Documentation Elements

Suggested clinical documentation elements include specific indication for the prosthesis, prior problems with socket suspension or fit, stump/residual-limb length and condition, functional assessment results (ADLs/IADLs), rehabilitation potential, prior trials of conventional sockets, and details of comorbidities that may affect outcomes (e.g., vascular disease, infection risk). For osseointegration requests, document prior conservative management and rationale for selecting an implant-based approach.

Indication and clinical history leading to amputation or congenital absence
Prior trial(s) and issues with conventional socket prosthesis (fit, suspension, skin breakdown)
Stump/residual limb length and tissue quality
Functional assessment (ADLs/IADLs), mobility and rehabilitation potential
Relevant comorbidities (e.g., vascular disease, diabetes) and infection risk assessment
For osseointegration: prior conservative measures and explicit rationale for implant selection

Documentation Required

Required Prescription Components

A complete prescription must accompany the request and include a comprehensive pre-prosthetic assessment, the prescribed device design and control strategy, anatomical side and amputation level, socket interface and frame type, suspension mechanism, and all specific components (terminal device, wrist/elbow/shoulder units as applicable). The prescription should reflect a collaborative decision-making process by the care team.

Comprehensive assessment summary (present health, cognition, limb exam, learning assessment)
Design: preparatory vs definitive
Control strategy: passive, body-powered, externally powered, hybrid
Anatomical side and amputation level
Socket interface and frame type
Suspension mechanism
List of specific components: terminal device, wrist/elbow/shoulder units

Note

Device Selection Considerations

Device selection should be individualized to match the member's functional needs, amputation level, and rehabilitation potential. Consider passive, body-powered, externally powered (myoelectric), or hybrid prostheses based on the patient’s strength, range of motion, ability to operate controls (including adequate EMG/microvolt signals for myoelectric devices), daily activity demands, and maintenance considerations.

Select device type to match function: passive, body-powered, externally powered (myoelectric), or hybrid
Assess patient ability to operate the chosen control strategy (EMG signal thresholds for myoelectric devices)
Consider durability, maintenance, battery needs, waterproofing, and cosmesis in device choice

Prior Authorization

Prior Trial of Conventional Socket Prosthesis

Prior to considering advanced options such as myoelectric systems or osseointegration, document a prior trial of a conventional socket prosthesis or provide justification why a socket is not feasible (e.g., very short residual limb, severe skin breakdown, or repeated failure of suspension). Failure of or intolerance to socket prostheses should be clearly described.

Documented trial(s) of conventional socket prosthesis and outcomes
If no trial was done, provide clinical justification why socket prosthesis is not feasible
Details of socket-related complications (pain, skin breakdown, poor suspension)

Documentation Required

Pre-Prosthetic Assessment Requirement

Care teams should perform pre-prosthetic training and a comprehensive assessment before prescribing an upper extremity prosthesis. Assessments should include present health status, level of function, modifiable health risks, pain, cognition, residual limb and contralateral limb assessment, learning ability, and vocational or social needs. Education of the patient and caregivers and documentation of willingness and ability to participate in prosthetic training are required.

Pre-prosthetic training to determine appropriate device type
Comprehensive assessment components (health, function, cognition, limb assessments, vocational)
Document patient/caregiver education and willingness/ability to engage in training

Assessment contextInstrumental ADLs (IADLs) are part of the recommended pre-prosthetic functional assessment.

Myoelectric Prosthetic

DefinitionA prosthetic device operated by battery-powered electric motors activated through electrodes that detect myoelectric potentials from muscles.

Control mechanismDevice movement is commanded by EMG signals captured by surface or implanted electrodes and processed by control electronics.

Clinical implicationRequires sufficient residual musculature and training; assessed during candidacy evaluation.

Prosthetist

DefinitionA healthcare professional who makes and fits artificial limbs (prostheses) for people with disabilities.

Role in careEvaluates prosthetic needs, conducts fittings, provides training, and collaborates with prescribing physician for device selection.

Supervision requirementProsthetic evaluation should be performed by a qualified prosthetic professional under physician supervision per policy requirements.

Osseointegration (bone‑anchored percutaneous prosthesis)

DefinitionSurgical implantation of a fixture into bone allowing direct skeletal attachment of a prosthesis through a percutaneous abutment; may include implanted electrodes for neuromusculoskeletal systems.

Typical use-caseReported in transhumeral amputations for direct attachment of advanced prostheses; associated with unique infection and implant-survival risks.

Policy stanceBone-anchored percutaneous limb prostheses (e.g., OPRA) are considered unproven and not medically necessary in this policy due to insufficient evidence.

Neuromusculoskeletal interface

DefinitionA neuromusculoskeletal interface combines osseointegration with implanted electrodes in muscles and nerves to enable bidirectional motor control and sensory feedback between prosthesis and user.

ComponentsImplanted epimysial or nerve electrodes plus osseointegrated skeletal fixation to permit intuitive control and graded sensory feedback.

Clinical evidenceSmall series report improved intuitive control and sensory feedback but also note infection and implant-failure risks requiring careful candidate selection.

Myoelectric prosthesis (MHP/SHP)

DefinitionAn externally powered prosthesis that senses EMG signals to command powered hand/wrist function; MHP = multi-grip prosthesis, SHP = standard single-grip prosthesis.

VariantsMay include powered wrists, multi-articulating hands, and classifier-based control strategies to support multiple grasps.

Training and controlPerformance influenced by training, classifier techniques, and prior prosthetic experience; evidence on superiority is limited and mixed.

Prostheses device classification

FDA device classificationMany prostheses are FDA class I devices exempt from premarket review; FDA clearance/denovo status is informational and not a coverage determination.

DEKA ArmThe DEKA Arm System received FDA de novo clearance in 2014 as a low- to moderate-risk device.

Coverage noteFDA status alone is not a basis for coverage; contractual, state, and federal benefit terms govern coverage decisions.

Dual-window classifier

DefinitionAn EMG pattern-recognition approach that switches between long and short analysis windows to improve partial‑hand prosthesis control and reduce classification error.

Effect on performanceDual-window classifier techniques have been shown to reduce time and attempts required for grasp selection and improve real‑time task completion in small studies.

Clinical implicationClassifier and windowing techniques can improve control accuracy and should be considered in device training and selection.