1. Ingeniería

COVERAGE DETERMINATION GUIDELINE
PROSTHETIC DEVICES, WIGS, SPECIALIZED,
MICROPROCESSOR OR MYOELECTRIC LIMBS
Guideline Number:
Effective Date:
CDG.018.03
February 1, 2015
Table of Contents
COVERAGE RATIONALE........................................
DEFINITIONS……………………………………………
APPLICABLE CODES..............................................
HISTORY/REVISION INFORMATION......................
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5
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Related Policies:
DME, Orthotics, Ostomy Supplies,
Medical Supplies and
Repairs/Replacements
INSTRUCTIONS FOR USE
This Coverage Determination Guideline provides assistance in interpreting certain standard
UnitedHealthcare benefit plans. When deciding coverage, the enrollee specific document must be
referenced. The terms of an enrollee’s document (e.g., Certificates of Coverage (COCs),
Schedules of Benefits (SOBs), or Summary Plan Descriptions (SPDs), and Medicaid State
Contracts) may differ greatly from the standard benefit plans upon which this guideline is based.
In the event of a conflict, the enrollee's specific benefit document supersedes these guidelines.
All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements
and the plan benefit coverage prior to use of this guideline. Other coverage determination
guidelines and medical policies may apply. UnitedHealthcare reserves the right, in its sole
discretion, to modify its coverage determination guidelines and medical policies as necessary.
This Coverage Determination Guideline does not constitute medical advice.
UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care
Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are
intended to be used in connection with the independent professional medical judgment of a
qualified health care provider and do not constitute the practice of medicine or medical advice.
COVERAGE RATIONALE
Benefit Document Language
Before using this guideline, please check enrollee’s specific benefit document and any federal or
state mandates, if applicable.
Essential Health Benefits for Individual and Small Group:
For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA)
requires fully insured non-grandfathered individual and small group plans (inside and outside of
Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large
group plans (both self-funded and fully insured), and small group ASO plans, are not subject to
the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage
for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar
limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The
determination of which benefits constitute EHBs is made on a state by state basis. As such,
when using this guideline, it is important to refer to the enrollee’s specific benefit document to
determine benefit coverage.
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Indications for Coverage
I.
Prosthetic Devices and Wigs
A determination of coverage for the prosthesis is based on the enrollee’s potential functional
abilities. Potential functional ability is based on the reasonable expectations of the prosthetist,
and treating physician, considering factors including, but not limited to:
• The enrollee’s past history (including prior prosthetic use if applicable); and
• The enrollee’s current condition including the status of the residual limb and the
nature of other medical problems.
1. Prosthetic device coverage is limited to those prosthetic devices that replace a limb or
external body part that are listed below:
• Artificial arms, legs, feet and hands
• Artificial eyes, ears and nose
• Breast prosthesis as required by the Women’s Health and Cancer Rights Act of 1998.
Benefits include mastectomy bras and lymphedema stockings for the arm.
• Speech aid prosthetics and tracheo-esophageal voice prosthesis. Although these
are typically external devices replacing the vocal cords, there may be an intra-oral
component. These devices are covered as either DME or Prosthetics. Please
check enrollee specific benefit document for coverage.
2. Prosthetic devices when covered, regardless of the setting or vendor from whom the
prosthetic device is dispensed, are covered under the Prosthetic Devices section of the
benefit document.
3. Prosthetic devices must be ordered by or under the direction of a physician.
4. The prosthetic device must be approved by the Food and Drug Administration (FDA) and
otherwise generally considered to be safe and effective for the purposes intended and
the item must be reasonable and necessary for the individual patient.
5. Breast prosthetics which include the breast prosthesis, mastectomy bra, and
lymphedema arm stockings, are always covered on an unlimited basis as to number of
items and dollar amounts covered as required by the Women’s Health and Cancer Act of
1998.
6. Implantable devices/prostheses, such as artificial heart valves, are not prosthetics. If
covered, these devices would be covered as a surgical service.
7. Coverage is available for repair and replacement, when it is not due to misuse, malicious
damage or gross neglect.
8. Several states mandate coverage for prosthetics. Please check the enrollee specific
benefit document for coverage.
II. Specialized, Microprocessor or Myoelectic Limbs
Computerized, bionic, microprocessor or myoelectric terms are considered the same for the
purpose of this policy. Some states may require coverage of prosthetics that
UnitedHealthcare may not otherwise consider covered.
Computerized or microprocessor limbs are based on a patient’s current functional capabilities
and his/her expected functional rehabilitation potential. If more than one prosthetic limb
meets a patient’s prosthetic rehabilitation needs, the least costly prosthetic will be approved.
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Evidence is insufficient to permit conclusions regarding the effect of a microprocessorcontrolled prosthesis on health outcomes in limited community ambulators. Evidence is also
insufficient to permit conclusions regarding the effect of a next-generation microprocessorcontrolled prosthesis on health outcomes. Therefore, these are considered investigational.
1. Computerized Prosthetic limbs are a covered health service when criteria are met:
a) Ordered by a physician; and
b) Patient is evaluated for his/her individual needs by a healthcare professional with the
qualifications and training and under the supervision of the ordering physician to
make an evaluation (documentation should accompany the order); and
c) Ordering physician signs the final prosthetic proposal; and
d) The records must document the patient’s current functional capabilities and his/her
expected functional rehabilitation potential, including an explanation for the
difference, if that is the case. (It is recognized within the functional classification
hierarchy that bilateral amputees often cannot be strictly bound by functional level
classifications); and
e) Prosthetic replaces all or part of a missing limb; and
f) Prosthetic will help patient regain or maintain function; and
g) Patient is willing and able to participate in the training for the use of the prosthetic
(especially important in use of a computerized upper limb); and
h) Patient is able to physically function at a level necessary for a computerized
prosthetic or microprocessor, e.g. hand, leg or foot
2. Coverage of computerized and specialized lower limb prostheses is based on maximum
prosthetic function level of the patient (see Lower Limb Rehabilitation Classification
Levels 1-4 under Definition section below.)
a) Patient meets criteria in #1 (one) above; and
b) Patient has or is able to gain Lower Limb Rehabilitation Classification Levels 3 or 4
for prosthetic ambulation (see Definition section below)
A. Microprocessor or specialized foot or feet;
i.
Microprocessor controlled ankle foot system (L5973), energy storing foot
(L5976), multi-axial ankle/foot (L5978), dynamic response foot with multiaxial ankle (L5979), flex foot system (L5980), flex-walk system or equal
(L5981), or shank foot system with vertical loading pylon (L5987) is indicated
for patients whose functional level is 3 or above. (A user adjustable heel
height feature (L5990) will be denied as not meeting criteria for coverage.
B. Knees: Basic lower extremity prostheses include a single axis, constant friction
knee. Other prosthetic knees are indicated based upon functional classification.
i. A high activity knee control frame (L5930) (e.g. i Ottobock C-Leg®
Microprocessor Knee System) is covered for patients whose function level is 4.
ii. A fluid, pneumatic, or electronic knee (L5610, L5613, L5614, L5722-L5780,
L5814, L5822-L5840, L5848, L5856, L5857, and L5858) is indicated for
patients whose functional level is 3 or above.
iii. L5859 is only covered when the enrollee meets all of the criteria below:
• Has a microprocessor (swing and stance phase type (L5856)) controlled
(electronic) knee
• K3 functional level only
• Weight greater than 110 lbs and less than 275 lbs
• Has a documented comorbity of the spine and/or sound limb affecting hip
extention and/or quadriceps function that impairs K-3 level function with the
use of a microprocessor-controlled knee alone
• Is able to make use of a product that requires daily charging
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•
Is able to understand and respond to error alerts and alarms indicating
problems with the function of the unit
C. Ankles:
i.
An axial rotation unit (L5982-L5986) is indicated for patients whose Lower
Limb Rehabilitation Classification is 2 or above.
ii.
A microprocessor controlled ankle foot system (L5973), energy storing foot
(L5976), dynamic response foot with multi-axial ankle (L5979), flex foot
system (L5980), flex-walk system or equal (L5981), or shank foot system
with vertical loading pylon (L5987) is covered for beneficiaries whose
functional level is 3 or above.
D. Sockets:
i. More than 2 test (diagnostic) sockets (L5618-L5628) for an individual
prosthesis are not indicated unless there is documentation in the medical
record which justifies the need. Exception: a test socket is not indicated for
an immediate prosthesis (L5400-L5460)
ii. No more than two of the same socket inserts (L5654-L5665, L5673, L5679,
L5681, and L5683) are allowed per individual prosthesis at the same time.
iii. Socket replacements are indicated if there is adequate documentation of
functional and/or physiological need. It is recognized that there are situations
where the explanation includes but is not limited to: changes in the residual
limb; functional need changes; or irreparable damage or wear/tear due to
excessive patient weight or prosthetic demands of very active amputees.
3. Myoelectric Upper Limbs (arms, joints and hands) are covered when criteria are met:
a) Patient meets all the criteria in #1 (one) above; and
b) Patient has a congenital missing or dysfunctional arm and/or hand; or
c) Patient has a traumatic or surgical amputation of the arm (above or below the elbow);
and
d) The remaining musculature of the arm(s) contains the minimum microvolt threshold
to allow operation of a myoelectric prosthetic device (usually 3-5 muscle groups must
be activated to use a computerized arm/hand); and
e) A standard body-powered prosthetic device cannot be used or is insufficient to meet
the functional needs of the individual in performing activities of daily living.
Coverage Limitations and Exclusions
1. Coverage for wigs/scalp hair prosthesis is excluded unless specifically listed as a
covered health service. Some states mandate coverage. Check the enrollee specific
benefit document for coverage. When wigs are covered, the benefit does not include
coverage for hair implants or hair plugs.
2. Coverage is not available for prosthetics if the patient is eligible through a governmental
program for a prosthetic due to military service related injuries and/or primary insurance
coverage, e.g., VA, Medicare or TriCare.
3. Replacement of prosthetic devices due to misuse, malicious damage or gross neglect or
to replace lost or stolen items. (Check enrollee specific benefit document)
4. Repairs to prosthetic devices due to misuse, malicious damage or gross neglect (Check
enrollee specific benefit document)
5. If more than one prosthetic device can meet the enrollees functional needs, benefits are
only available for the prosthetic device that meets the minimum specifications for the
enrollees needs.
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6. Coverage beyond any dollar or frequency limits specified in the enrollees specific benefit
documents.
DEFINITIONS
Lower Limb Rehabilitation Classification Levels
•
For Lower Limb Determinations: A clinical assessments of patient rehabilitation potential
must be based on the following classification levels:

K-Level 0: Does not have the ability or potential to ambulate or transfer safely with or
without assistance and prosthesis does not enhance their quality of life or mobility.

K-Level 1: Has the ability or potential to use prosthesis for transfers or ambulation on
level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.

K-Level 2: Has the ability or potential for ambulation with the ability to traverse low level
environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited
community ambulator.

K-Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the
community ambulator who has the ability to traverse most environmental barriers and
may have vocational, therapeutic, or exercise activity that demands prosthetic utilization
beyond simple locomotion.

K-Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic
ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic
demands of the child, active adult, or athlete.
Microprocessor Controlled Ankle Foot Prosthesis: (e.g., Proprio Foot) is able to actively
change the ankle angle and to identify sloping gradients and ascent or descent of stairs as the
result of microprocessor-control and sensor technology.
Microprocessor Controlled Lower Limb Prostheses: Microprocessor controlled knees offer
dynamic control through sensors in the shin. Microprocessor controlled knees attempt to simulate
normal biological knee function by offering variable resistance control to the swing or stance
phases of the gait cycle. This allows the user to safely perform ramp and stair descent in a stepover-step manner. The swing-rate adjustments allow the knee to respond to rapid changes in
cadence. Microprocessor controlled knee flexion enhances the stumble recovery capability of the
patient by preventing unexpected knee buckling. Prosthetic knees such as the microprocessor
controlled knee that focus on better control of flexion abilities without reducing stability have the
potential to improve gait pattern, wearer confidence, and safety of ambulation. The
microprocessor knee is more beneficial at higher ambulation speed in physically fit patients.
®
Available devices include but are not limited to Otto-Bock C-Leg device , the Ossur
®
®
RheoKnee or the Endolite Intelligent Prosthesis
A microprocessor controlled ankle foot prosthesis (e.g., Proprio Foot) is able to actively change
the ankle angle and to identify sloping gradients and ascent or descent of stairs as the result of
microprocessor-control and sensor technology.
Myoelectric Prosthetic: A myoelectric prosthesis uses electromyography signals or potentials
from voluntarily contracted muscles within a person’s residual limb via the surface of the skin to
control the movements of the prosthesis, such as elbow flexion/extension, wrist
supination/pronation or hand opening/closing of the fingers. Prosthesis of this type utilizes the
residual neuro-muscular system of the human body to control the functions of an electric powered
prosthetic hand, wrist or elbow. This is as opposed to a traditional electric switch prosthesis,
which requires straps and/or cables actuated by body movements to actuate or operate switches
that control the movements of a prosthesis or one that is totally mechanical. It has a selfProsthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
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suspending socket with pick up electrodes placed over flexors and extensors for the movement of
flexion and extension respectively.
Prosthetist: A person, who measures, designs, fabricates, fits, or services a prosthesis as
prescribed by a licensed physician, and who assists in the formulation of the prosthesis
prescription for the replacement of external parts of the human body lost due to amputation or
congenital deformities or absences. A prosthetist is a person that has been certified to fit
prostheses to residual limbs of the upper and lower extremities.
Prosthetic Device: An external device that replaces all or part of a missing body part.
Upper Limb Prosthetic Categories
(Upper limb prostheses are classified into 3 categories depending on the means of generating
movement at the joints: passive, body-powered, and electrically powered movement):
•
The passive prosthesis is the lightest of the three types and is described as the most
comfortable. Since the passive prosthesis must be repositioned manually, typically by
moving it with the opposite arm, it cannot restore function.
•
The body-powered prosthesis utilizes a body harness and cable system to provide
functional manipulation of the elbow and hand. Voluntary movement of the shoulder
and/or limb stump extends the cable and transmits the force to the terminal device.
Prosthetic hand attachments, which may be claw-like devices that allow good grip
strength and visual control of objects or latex-gloved devices that provide a more natural
appearance at the expense of control, can be opened and closed by the cable system.
Patient complaints with body-powered prostheses include harness discomfort, particularly
the wear temperature, wire failure, and the unattractive appearance.
•
Myoelectric prostheses use muscle activity from the remaining limb for the control of joint
movement. Electromyographic (EMG) signals from the limb stump are detected by
surface electrodes, amplified, and then processed by a controller to drive batterypowered motors that move the hand, wrist, or elbow. Although upper arm movement may
be slow and limited to one joint at a time, myoelectric control of movement may be
considered the most physiologically natural. Myoelectric hand attachments are similar in
form to those offered with the body-powered prosthesis, but are battery powered. An
example of recently available technology is the SensorHand™ by Advanced Arm
Dynamics, which is described as having an AutoGrasp feature, an opening/closing speed
of up to 300 mm/second, and advanced EMG signal processing. Patient dissatisfaction
with myoelectric prostheses includes the increased cost, maintenance (particularly for the
glove), and weight.
•
A hybrid system, a combination of body-powered and myoelectric components, may be
used for high-level amputations (at or above the elbow). Hybrid systems allow control of
two joints at once (i.e., one body-powered and one myoelectric) and are generally lighter
and less expensive than a prosthesis composed entirely of myoelectric components
APPLICABLE CODES
®
The Current Procedural Terminology (CPT ), Healthcare Common Procedure Coding System
®
(HCPCS) and Current Dental Terminology (CDT ) codes listed in this guideline are for reference
purposes only. Listing of a service code in this guideline does not imply that the service described
by this code is a covered or non-covered health service. Coverage is determined by the enrollee
specific benefit document and applicable laws that may require coverage for a specific service.
The inclusion of a code does not imply any right to reimbursement or guarantee claims
payment. Other policies and coverage determination guidelines may apply.
®
CPT is a registered trademark of the American Medical Association.
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®
CDT is a registered trademark of the American Dental Association.
Limited to specific
procedure codes?
YES
NO
HCPCS
Description
Procedure Code
SPEECH AID PROSTHETICS AND TRACHEO-ESOPHAGEAL VOICE PROSTHETICS
Please note:
• For groups on the 2001 COC, the following items are covered as durable medical equipment.
For groups on the 2007 COC, the following items are covered as prosthetic devices.
• For groups on the 2007 COC, a business decision was made to remove these items from
prosthetics and cover as DME on the amendment and refilling of the 2007 COC due to the
federal mandates. However, the filings need to be approved by the state, so the state
specific filing must be reviewed to determine if coverage is provided under DME or
prosthetics.
• For groups on the 2011 COC, these are covered as DME.
D5952
Speech aid prosthesis, pediatric
D5953
Speech aid prosthesis, adult
D5960
Speech aid prosthesis, modification
L8500
Artificial larynx, anytype
Tracheo-esophageal voice prosthesis,
L8507
Patient inserted, any type, each
Tracheo-esophageal voice prosthesis,
L8509
Inserted by a licensed health care provider, any type
BREAST PROSTHESIS
Please note: The codes listed under "breast prosthesis" are always covered even when
exclusion for prosthetic devices exists. Coverage is required for these codes per the Women's
Health and Cancer Rights Act of 1998.
Adhesive skin support attachment for use with external breast
A4280
prosthesis, each
Breast prosthesis, mastectomy bra,without integrated breast
L8000
prosthesis form, any size, any type
Breast prosthesis mastectomy bra, with integrated breast prosthesis
L8001
form, unilateral, any size, any type
Breast prosthesis mastectomy bra, with integrated breast prosthesis
L8002
form, bilateral, any size, any type
L8010
Breast prosthesis mastectomy sleeve
L8015
Ext brst prosthesis garment w/ form post mastectomy
L8020
Breast prosthesis mastectomy form
L8030
Breast prosthesis silicone or equal
L8031
Breast prostheiis, silcone or equal, with integral adhesive
L8032
Nipple prosthesis, reusable, and type each
L8035
Cstm breast prosthesis molded to pt post mastectmy
L8039
Breast prosthesis, nos
S8420
Gradient pressure aid sleeve & glove custom made
S8421
Gradient pressure aid sleeve & glove ready made
S8422
Gradient pressure aid sleeve cstm made med wt
S8423
Gradient pressure aid sleeve cstm made heavy wt
S8424
Gradient pressure aid sleeve ready made
S8425
Gradient pressure aid glove cstm made med wt
S8426
Gradient pressure aid glove cstm made heavy wt
S8427
Gradient pressure aid glove ready made
S8428
Gradient pressure aid gauntlet ready made
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HCPCS
Procedure Code
S8429
S8460
EYE PROSTHESIS
D5915
D5916
D5923
D5928
L8042
L8610
V2623
V2624
V2625
V2626
V2627
V2628
V2629
NOSE PROSTHESIS
D5913
D5922
D5926
L8040
L8047
FACIAL PROSTHESIS
D5911
D5912
D5919
D5929
L8041
L8043
L8044
L8046
L8048
L8049
Description
Gradient pressure exterior wrap
Camisole postmastectomy
Orbital prosthesis
Ocular prosthesis
Ocular prosthesis, interim
Orbital prosthesis, replacement
Orbital prosthesis provided by nonphysician
Ocular implant
Prosthetic eye plastic cstm
Polish/resurfacing of ocular prosthesis
Enlargement of ocular prosthesis
Reduction of ocular prosthesis
Scleral cover shell
Fabrication/fitting of ocular conformer
Prosthetic eye, other type
Nasal prosthesis
Nasal septal prosthesis
Nasal prosthesis, replacement
Nasal prosthesis provided by nonphysician
Nasal septal prosthesis prov by nonphysician
Facial moulage (sectional)
Facial moulage (complete)
Facial prosthesis
Facial prosthesis, replacement
Midfacial prosthesis, provided by a non-physician
Upper facial prosthesis, provided by a non-physician
Hemi-facial prosthesis, provided by a non-physician
Partial facial prosthesis, provided by a non-physician
Unspecified maxillofacial prosthesis, by report, provided by a nonphysician
Repair or modification of maxillofacial prosthesis, labor component,
15 minute increments, provided by a non-physician
EAR PROSTHESIS
D5914
Auricular prosthesis
D5927
Auricular prosthesis, replacement
L8045
Auricular prosthesis provided by nonphysician
LOWER LIMB PROSTHETICS
L5000
Partial foot, shoe insert with longitudinal arch, toe filler
L5010
Partial foot, molded socket, ankle height, with toe filler
L5020
Partial foot, molded socket, tibial tubercle height, with toe filler
L5050
Ankle, symes, molded socket, sach foot
Ankle, symes, metal frame, molded leather socket, articulated
L5060
ankle/foot
L5100
Below knee, molded socket, shin, sach foot
L5105
Below knee, plastic socket, joints and thigh lacer, sach foot
Knee disarticulation (or through knee), molded socket, external knee
L5150
joints, shin, sach foot
Knee disarticulation (or through knee), molded socket, bent knee
L5160
configuration, external knee joints, shin, sach foot
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HCPCS
Procedure Code
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5301
L5312
L5321
L5331
L5341
L5400
L5410
L5420
L5430
L5450
L5460
L5500
L5505
L5510
L5520
L5530
L5535
Description
Above knee, molded socket, single axis constant friction knee, shin,
sach foot
Above knee, short prosthesis, no knee joint (stubbies), with foot
blocks, no ankle joints, each
Above knee, short prosthesis, no knee joint (stubbies), with
articulated ankle/foot, dynamically aligned, each
Above knee, for proximal femoral focal deficiency, constant friction
knee, shin, sach foot
Hip disarticulation, canadian type; molded socket, hip joint, single axis
constant friction knee, shin, sach foot
Hip disarticulation, tilt table type; molded socket, locking hip joint,
single axis constant friction knee, shin, sach foot
Hemipelvectomy, canadian type; molded socket, hip joint, single axis
constant friction knee, shin, sach foot
Below knee, molded socket, shin, sach foot, endoskeletal system
Knee disarticulation (or through knee), molded socket, single axis
knee, pylon,
Above knee, molded socket, open end, sach foot, endoskeletal
system, single axis knee
Hip disarticulation, canadian type, molded socket, endoskeletal
system, hip joint, single axis knee, sach foot
Hemipelvectomy, canadian type, molded socket, endoskeletal
system, hip joint, single axis knee, sach foot
Immediate postsurgical or early fitting, application of initial rigid
dressing, including fitting, alignment, suspension, and one cast
change, below knee
Immediate postsurgical or early fitting, application of initial rigid
dressing, including fitting, alignment and suspension, below knee,
each additional cast change and realignment
Immediate postsurgical or early fitting, application of initial rigid
dressing, including fitting, alignment and suspension and one cast
change ak or knee disarticulation
Immediate postsurgical or early fitting, application of initial rigid
dressing, including fitting, alignment and suspension, ak or knee
disarticulation, each additional cast change and realignment
Immediate postsurgical or early fitting, application of nonweight
bearing rigid dressing, below knee
Immediate postsurgical or early fitting, application of nonweight
bearing rigid dressing, above knee
Initial, below knee ptb type socket, nonalignable system, pylon, no
cover, sach foot, plaster socket, direct formed
Initial, above knee, knee disarticulation, ischial level socket,
nonalignable system, pylon, no cover, sach foot, plaster socket, direct
formed
Preparatory, below knee ptb type socket, nonalignable system, pylon,
no cover, sach foot, plaster socket, molded to model
Preparatory, below knee ptb type socket, nonalignable system, pylon,
no cover, sach foot, thermoplastic or equal, direct formed
Preparatory, below knee ptb type socket, nonalignable system, pylon,
no cover, sach foot, thermoplastic or equal, molded to model
Preparatory, below knee ptb type socket, nonalignable system, no
cover, sach foot, prefabricated, adjustable open end socket
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HCPCS
Procedure Code
L5540
L5560
L5570
L5580
L5585
L5590
L5595
L5600
L5610
L5611
L5613
L5614
L5616
L5617
L5618
L5620
L5622
L5624
L5626
L5628
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5639
L5640
L5642
Description
Preparatory, below knee ptb type socket, nonalignable system, pylon,
no cover, sach foot, laminated socket, molded to model
Preparatory, above knee, knee disarticulation, ischial level socket,
nonalignable system, pylon, no cover, sach foot, plaster socket,
molded to model
Preparatory, above knee - knee disarticulation, ischial level socket,
nonalignable system, pylon, no cover, sach foot, thermoplastic or
equal, direct formed
Preparatory, above knee, knee disarticulation, ischial level socket,
nonalignable system, pylon, no cover, sach foot, thermoplastic or
equal, molded to model
Preparatory, above knee - knee disarticulation, ischial level socket,
nonalignable system, pylon, no cover, sach foot, prefabricated
adjustable open end socket
Preparatory, above knee, knee disarticulation, ischial level socket,
nonalignable system, pylon, no cover, sach foot, laminated socket,
molded to model
Preparatory, hip disarticulation/hemipelvectomy, pylon, no cover,
sach foot, thermoplastic or equal, molded to patient model
Preparatory, hip disarticulation/hemipelvectomy, pylon, no cover,
sach foot, laminated socket, molded to patient model
Addition to lower extremity, endoskeletal system, above knee,
hydracadence system
Addition to lower extremity, endoskeletal system, above knee, knee
disarticulation, 4-bar linkage, with friction swing phase control
Addition to lower extremity, endoskeletal system, above knee, knee
disarticulation, 4-bar linkage, with hydraulic swing phase control
Addition to lower extremity, exoskeletal system, above knee-knee
disarticulation, 4 bar linkage, with pneumatic swing phase control
Addition to lower extremity, endoskeletal system, above knee,
universal multiplex system, friction swing phase control
Addition to lower extremity, quick change self-aligning unit, above
knee or below knee, each
Addition to lower extremity, test socket, symes
Addition to lower extremity, test socket, below knee
Addition to lower extremity, test socket, knee disarticulation
Addition to lower extremity, test socket, above knee
Addition to lower extremity, test socket, hip disarticulation
Addition to lower extremity, test socket, hemipelvectomy
Addition to lower extremity, below knee, acrylic socket
Addition to lower extremity, symes type, expandable wall socket
Addition to lower extremity, above knee or knee disarticulation, acrylic
socket
Addition to lower extremity, symes type, ptb brim design socket
Addition to lower extremity, symes type, posterior opening (canadian)
socket
Addition to lower extremity, symes type, medial opening socket
Addition to lower extremity, below knee, total contact
Addition to lower extremity, below knee, leather socket
Addition to lower extremity, below knee, wood socket
Addition to lower extremity, knee disarticulation, leather socket
Addition to lower extremity, above knee, leather socket
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
Proprietary Information of UnitedHealthcare. Copyright 2015United HealthCare Services, Inc.
10
HCPCS
Procedure Code
L5643
L5644
L5645
L5646
L5647
L5648
L5649
L5650
L5651
L5652
L5653
L5654
L5655
L5656
L5658
L5661
L5665
L5666
L5668
L5670
L5671
L5672
L5673
L5676
L5677
L5678
L5679
L5680
L5681
Description
Addition to lower extremity, hip disarticulation, flexible inner socket,
external frame
Addition to lower extremity, above knee, wood socket
Addition to lower extremity, below knee, flexible inner socket, external
frame
Addition to lower extremity, below knee, air, fluid, gel or equal,
cushion socket
Addition to lower extremity, below knee, suction socket
Addition to lower extremity, above knee, air, fluid, gel or equal,
cushion socket
Addition to lower extremity, ischial containment/narrow m-l socket
Additions to lower extremity, total contact, above knee or knee
disarticulation socket
Addition to lower extremity, above knee, flexible inner socket, external
frame
Addition to lower extremity, suction suspension, above knee or knee
disarticulation socket
Addition to lower extremity, knee disarticulation, expandable wall
socket
Addition to lower extremity, socket insert, symes, (kemblo, pelite,
aliplast, plastazote or equal)
Addition to lower extremity, socket insert, below knee (kemblo, pelite,
aliplast, plastazote or equal)
Addition to lower extremity, socket insert, knee disarticulation
(kemblo, pelite, aliplast, plastazote or equal)
Addition to lower extremity, socket insert, above knee (kemblo, pelite,
aliplast, plastazote or equal)
Addition to lower extremity, socket insert, multidurometer symes
Addition to lower extremity, socket insert, multidurometer, below knee
Addition to lower extremity, below knee, cuff suspension
Addition to lower extremity, below knee, molded distal cushion
Addition to lower extremity, below knee, molded supracondylar
suspension (pts or similar)
Addition to lower extremity, below knee / above knee suspension
locking mechanism (shuttle, lanyard, or equal), excludes socket insert
Addition to lower extremity, below knee, removable medial brim
suspension
Addition to lower extremity, below knee/above knee, custom
fabricated from existing mold or prefabricated, socket insert, silicone
gel, elastomeric or equal, for use with locking mechanism
Additions to lower extremity, below knee, knee joints, single axis, pair
Additions to lower extremity, below knee, knee joints, polycentric, pair
Additions to lower extremity, below knee, joint covers, pair
Addition to lower extremity, below knee/above knee, custom
fabricated from existing mold or prefabricated, socket insert, silicone
gel, elastomeric or equal, not for use with locking mechanism
Addition to lower extremity, below knee, thigh lacer, nonmolded
Addition to lower extremity, below knee/above knee, custom
fabricated socket insert for congenital or atypical traumatic amputee,
silicone gel, elastomeric or equal, for use with or without locking
mechanism, initial only (for other than initial, use code l5673 or l5679)
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
Proprietary Information of UnitedHealthcare. Copyright 2015United HealthCare Services, Inc.
11
HCPCS
Procedure Code
L5682
L5683
L5684
L5685
L5686
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
L5700
L5701
L5702
L5703
L5704
L5705
L5706
L5707
L5710
L5711
L5712
L5714
L5716
L5718
L5722
L5724
Description
Addition to lower extremity, below knee, thigh lacer, gluteal/ischial,
molded
Addition to lower extremity, below knee/above knee, custom
fabricated socket insert for other than congenital or atypical traumatic
amputee, silicone gel, elastomeric or equal, for use with or without
locking mechanism, initial only (for other than initial, use code l5673
or l5679)
Addition to lower extremity, below knee, fork strap
Addition to lower extremity prosthesis, below knee,
suspension/sealing sleeve, with or without valve, any material, each
Addition to lower extremity, below knee, back check (extension
control)
Addition to lower extremity, below knee, waist belt, webbing
Addition to lower extremity, below knee, waist belt, padded and lined
Addition to lower extremity, above knee, pelvic control belt, light
Addition to lower extremity, above knee, pelvic control belt, padded
and lined
Addition to lower extremity, above knee, pelvic control, sleeve
suspension, neoprene or equal, each
Addition to lower extremity, above knee or knee disarticulation, pelvic
joint
Addition to lower extremity, above knee or knee disarticulation, pelvic
band
Addition to lower extremity, above knee or knee disarticulation,
silesian bandage
All lower extremity prostheses, shoulder harness
Replacement, socket, below knee, molded to patient model
Replacement, socket, above knee/knee disarticulation, including
attachment plate, molded to patient model
Replacement, socket, hip disarticulation, including hip joint, molded to
patient model
Ankle, symes, molded to patient model, socket without solid ankle
cushion heel (sach) foot, replacement only
Custom shaped protective cover, below knee
Custom shaped protective cover, above knee
Custom shaped protective cover, knee disarticulation
Custom shaped protective cover, hip disarticulation
Addition, exoskeletal knee-shin system, single axis, manual lock
Additions exoskeletal knee-shin system, single axis, manual lock,
ultra-light material
Addition, exoskeletal knee-shin system, single axis, friction swing and
stance phase control (safety knee)
Addition, exoskeletal knee-shin system, single axis, variable friction
swing phase control
Addition, exoskeletal knee-shin system, polycentric, mechanical
stance phase lock
Addition, exoskeletal knee-shin system, polycentric, friction swing and
stance phase control
Addition, exoskeletal knee-shin system, single axis, pneumatic swing,
friction stance phase control
Addition, exoskeletal knee-shin system, single axis, fluid swing phase
control
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
Proprietary Information of UnitedHealthcare. Copyright 2015United HealthCare Services, Inc.
12
HCPCS
Procedure Code
L5726
L5728
L5780
L5781
L5782
L5785
L5790
L5795
L5810
L5811
L5812
L5814
L5816
L5818
L5822
L5824
L5826
L5828
L5830
L5840
L5845
L5848
L5850
L5855
L5856
L5857
Description
Addition, exoskeletal knee/shin system, single axis, external joints,
fluid swing phase control
Addition, exoskeletal knee-shin system, single axis, fluid swing and
stance phase control
Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra
pneumatic swing phase control
Addition to lower limb prosthesis, vacuum pump, residual limb volume
management and moisture evacuation system
Addition to lower limb prosthesis, vacuum pump, residual limb volume
management and moisture evacuation system, heavy-duty
Addition, exoskeletal system, below knee, ultra-light material
(titanium, carbon fiber or equal)
Addition, exoskeletal system, above knee, ultra-light material
(titanium, carbon fiber or equal)
Addition, exoskeletal system, hip disarticulation, ultra-light material
(titanium, carbon fiber or equal)
Addition, endoskeletal knee-shin system, single axis, manual lock
Addition, endoskeletal knee-shin system, single axis, manual lock,
ultra-light material
Addition, endoskeletal knee-shin system, single axis, friction swing
and stance phase control (safety knee)
Addition, endoskeletal knee-shin system, polycentric, hydraulic swing
phase control, mechanical stance phase lock
Addition, endoskeletal knee-shin system, polycentric, mechanical
stance phase lock
Addition, endoskeletal knee/shin system, polycentric, friction swing
and stance phase control
Addition, endoskeletal knee-shin system, single axis, pneumatic
swing, friction stance phase control
Addition, endoskeletal knee-shin system, single axis, fluid swing
phase control
Addition, endoskeletal knee-shin system, single axis, hydraulic swing
phase control, with miniature high activity frame
Addition, endoskeletal knee-shin system, single axis, fluid swing and
stance phase control
Addition, endoskeletal knee/shin system, single axis,
pneumatic/swing phase control
Addition, endoskeletal knee/shin system, 4-bar linkage or multiaxial,
pneumatic swing phase control
Addition, endoskeletal knee/shin system, stance flexion feature,
adjustable
Addition to endoskeletal knee-shin system, fluid stance extension,
dampening feature, with or without adjustability
Addition, endoskeletal system, above knee or hip disarticulation, knee
extension assist
Addition, endoskeletal system, hip disarticulation, mechanical hip
extension assist
Addition to lower extremity prosthesis, endoskeletal knee-shin
system, microprocessor control feature, swing and stance phase,
includes electronic sensor(s), any type
Addition to lower extremity prosthesis, endoskeletal knee-shin
system, microprocessor control feature, swing phase only, includes
electronic sensor(s), any type
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
Proprietary Information of UnitedHealthcare. Copyright 2015United HealthCare Services, Inc.
13
HCPCS
Procedure Code
L5858
L5859
L5910
L5920
L5925
L5930
L5940
L5950
L5960
L5961
L5962
L5964
L5966
L5968
L5969
L5970
L5971
L5972
L5973
L5974
L5975
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5985
L5986
Description
Addition to lower extremity prosthesis, endoskeletal knee shin
system, microprocessor control feature, stance phase only, includes
electronic sensor(s), any type
Addition to lower extremity prosthesis, endoskeletal knee-shin
system, powered and programmable flexion/extension assist control,
includes any type motor(s)
Addition, endoskeletal system, below knee, alignable system
Addition, endoskeletal system, above knee or hip disarticulation,
alignable system
Addition, endoskeletal system, above knee, knee disarticulation or hip
disarticulation, manual lock
Addition, endoskeletal system, high activity knee control frame
Addition, endoskeletal system, below knee, ultra-light material
(titanium, carbon fiber or equal)
Addition, endoskeletal system, above knee, ultra-light material
(titanium, carbon fiber or equal)
Addition, endoskeletal system, hip disarticulation, ultra-light material
(titanium, carbon fiber or equal)
Addition, endoskeletal system, polycentric hip joint, pneumatic or
hydraulic control, rotation control, with or without flexion and/or
extension control
Addition, endoskeletal system, below knee, flexible protective outer
surface covering system
Addition, endoskeletal system, above knee, flexible protective outer
surface covering system
Addition, endoskeletal system, hip disarticulation, flexible protective
outer surface covering system
Addition to lower limb prosthesis, multiaxial ankle with swing phase
active dorsiflexion feature
Addition, endoskeletal ankle-foot or ankle system, power assist,
includes any type motor(s)
All lower extremity prostheses, foot, external keel, sach foot
All lower extremity prosthesis, solid ankle cushion heel (sach) foot,
replacement only
All lower extremity prostheses, flexible keel
Endoskeletal ankle foot system, microprocessor controlled feature,
dorsiflexion and/or plantar flexion control, includes power source
All lower extremity prostheses, foot, single axis ankle/foot
All lower extremity prosthesis, combination single axis ankle and
flexible keel foot
All lower extremity prostheses, energy storing foot (seattle carbon
copy ii or equal)
All lower extremity prostheses, foot, multiaxial ankle/foot
All lower extremity prostheses, multiaxial ankle, dynamic response
foot, one piece system
All lower extremity prostheses, flex-foot system
All lower extremity prostheses, flex-walk system or equal
All exoskeletal lower extremity prostheses, axial rotation unit
All endoskeletal lower extremity prosthesis, axial rotation unit, with or
without adjustability
All endoskeletal lower extremity prostheses, dynamic prosthetic pylon
All lower extremity prostheses, multiaxial rotation unit (mcp or equal)
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
Proprietary Information of UnitedHealthcare. Copyright 2015United HealthCare Services, Inc.
14
HCPCS
Procedure Code
Description
All lower extremity prosthesis, shank foot system with vertical loading
pylon
Addition to lower limb prosthesis, vertical shock reducing pylon
L5988
feature
L5990
Addition to lower extremity prosthesis, user adjustable heel height
L5999
Lower extremity prosthesis, not otherwise specified
UPPER LIMB PROSTHETICS
L6000
Partial hand, robin-aids, thumb remaining (or equal)
L6010
Partial hand, robin-aids, little and/or ring finger remaining (or equal)
L6020
Partial hand, robin-aids, no finger remaining (or equal)
L5987
L6026
L6050
L6055
L6100
L6110
L6120
L6130
L6200
L6205
L6250
L6300
L6310
L6320
L6350
L6360
L6370
L6380
L6382
L6384
L6386
L6388
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)
Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad
Wrist disarticulation, molded socket with expandable interface, flexible
elbow hinges, triceps pad
Below elbow, molded socket, flexible elbow hinge, triceps pad
Below elbow, molded socket (muenster or northwestern suspension
types)
Below elbow, molded double wall split socket, step-up hinges, half
cuff
Below elbow, molded double wall split socket, stump activated locking
hinge, half cuff
Elbow disarticulation, molded socket, outside locking hinge, forearm
Elbow disarticulation, molded socket with expandable interface,
outside locking hinges, forearm
Above elbow, molded double wall socket, internal locking elbow,
forearm
Shoulder disarticulation, molded socket, shoulder bulkhead, humeral
section, internal locking elbow, forearm
Shoulder disarticulation, passive restoration (complete prosthesis)
Shoulder disarticulation, passive restoration (shoulder cap only)
Interscapular thoracic, molded socket, shoulder bulkhead, humeral
section, internal locking elbow, forearm
Interscapular thoracic, passive restoration (complete prosthesis)
Interscapular thoracic, passive restoration (shoulder cap only)
Immediate postsurgical or early fitting, application of initial rigid
dressing, including fitting alignment and suspension of components,
and one cast change, wrist disarticulation or below elbow
Immediate postsurgical or early fitting, application of initial rigid
dressing including fitting alignment and suspension of components,
and one cast change, elbow disarticulation or above elbow
Immediate postsurgical or early fitting, application of initial rigid
dressing including fitting alignment and suspension of components,
and one cast change, shoulder disarticulation or interscapular
thoracic
Immediate postsurgical or early fitting, each additional cast change
and realignment
Immediate postsurgical or early fitting, application of rigid dressing
only
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
Proprietary Information of UnitedHealthcare. Copyright 2015United HealthCare Services, Inc.
15
HCPCS
Procedure Code
L6400
L6450
L6500
L6550
L6570
L6580
L6582
L6584
L6586
L6588
L6590
L6600
L6605
L6610
L6611
L6615
L6616
L6620
L6621
L6623
L6624
L6625
L6628
L6629
L6630
L6632
Description
Below elbow, molded socket, endoskeletal system, including soft
prosthetic tissue shaping
Elbow disarticulation, molded socket, endoskeletal system, including
soft prosthetic tissue shaping
Above elbow, molded socket, endoskeletal system, including soft
prosthetic tissue shaping
Shoulder disarticulation, molded socket, endoskeletal system,
including soft prosthetic tissue shaping
Interscapular thoracic, molded socket, endoskeletal system, including
soft prosthetic tissue shaping
Preparatory, wrist disarticulation or below elbow, single wall plastic
socket, friction wrist, flexible elbow hinges, figure of eight harness,
humeral cuff, bowden cable control, usmc or equal pylon, no cover,
molded to patient model
Preparatory, wrist disarticulation or below elbow, single wall socket,
friction wrist, flexible elbow hinges, figure of eight harness, humeral
cuff, bowden cable control, usmc or equal pylon, no cover, direct
formed
Preparatory, elbow disarticulation or above elbow, single wall plastic
socket, friction wrist, locking elbow, figure of eight harness, fair lead
cable control, usmc or equal pylon, no cover, molded to patient model
Preparatory, elbow disarticulation or above elbow, single wall socket,
friction wrist, locking elbow, figure of eight harness, fair lead cable
control, usmc or equal pylon, no cover, direct formed
Preparatory, shoulder disarticulation or interscapular thoracic, single
wall plastic socket, shoulder joint, locking elbow, friction wrist, chest
strap, fair lead cable control, usmc or equal pylon, no cover, molded
to patient model
Preparatory, shoulder disarticulation or interscapular thoracic, single
wall socket, shoulder joint, locking elbow, friction wrist, chest strap,
fair lead cable control, usmc or equal pylon, no cover, direct formed
Upper extremity additions, polycentric hinge, pair
Upper extremity additions, single pivot hinge, pair
Upper extremity additions, flexible metal hinge, pair
Addition to upper extremity prosthesis, external powered, additional
switch, any type
Upper extremity addition, disconnect locking wrist unit
Upper extremity addition, additional disconnect insert for locking wrist
unit, each
Upper extremity addition, flexion/extension wrist unit, with or without
friction
Upper extremity prosthesis addition, flexion/extension wrist with or
without friction, for use with external powered terminal device
Upper extremity addition, spring assisted rotational wrist unit with
latch release
Upper extremity addition, flexion/extension and rotation wrist unit
Upper extremity addition, rotation wrist unit with cable lock
Upper extremity addition, quick disconnect hook adapter, otto bock or
equal
Upper extremity addition, quick disconnect lamination collar with
coupling piece, otto bock or equal
Upper extremity addition, stainless steel, any wrist
Upper extremity addition, latex suspension sleeve, each
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
Proprietary Information of UnitedHealthcare. Copyright 2015United HealthCare Services, Inc.
16
HCPCS
Procedure Code
L6635
L6637
L6638
L6640
L6641
L6642
L6645
L6646
L6647
L6648
L6650
L6655
L6660
L6665
L6670
L6672
L6675
L6676
L6677
L6680
L6682
L6684
L6686
L6687
L6688
L6689
L6690
L6691
L6692
L6693
L6694
L6695
Description
Upper extremity addition, lift assist for elbow
Upper extremity addition, nudge control elbow lock
Upper extremity addition to prosthesis, electric locking feature, only
for use with manually powered elbow
Upper extremity additions, shoulder abduction joint, pair
Upper extremity addition, excursion amplifier, pulley type
Upper extremity addition, excursion amplifier, lever type
Upper extremity addition, shoulder flexion-abduction joint, each
Upper extremity addition, shoulder joint, multipositional locking,
flexion, adjustable abduction friction control, for use with body
powered or external powered system
Upper extremity addition, shoulder lock mechanism, body powered
actuator
Upper extremity addition, shoulder lock mechanism, external powered
actuator
Upper extremity addition, shoulder universal joint, each
Upper extremity addition, standard control cable, extra
Upper extremity addition, heavy-duty control cable
Upper extremity addition, teflon, or equal, cable lining
Upper extremity addition, hook to hand, cable adapter
Upper extremity addition, harness, chest or shoulder, saddle type
Upper extremity addition, harness, (e.g., figure of eight type), single
cable design
Upper extremity addition, harness, (e.g., figure of eight type), dual
cable design
Upper extremity addition, harness, triple control, simultaneous
operation of terminal device and elbow
Upper extremity addition, test socket, wrist disarticulation or below
elbow
Upper extremity addition, test socket, elbow disarticulation or above
elbow
Upper extremity addition, test socket, shoulder disarticulation or
interscapular thoracic
Upper extremity addition, suction socket
Upper extremity addition, frame type socket, below elbow or wrist
disarticulation
Upper extremity addition, frame type socket, above elbow or elbow
disarticulation
Upper extremity addition, frame type socket, shoulder disarticulation
Upper extremity addition, frame type socket, interscapular-thoracic
Upper extremity addition, removable insert, each
Upper extremity addition, silicone gel insert or equal, each
Upper extremity addition, locking elbow, forearm counterbalance
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
Addition to upper extremity prosthesis, below elbow/above elbow,
custom fabricated from existing mold or prefabricated, socket insert,
silicone gel, elastomeric or equal, not for use with locking mechanism
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
Proprietary Information of UnitedHealthcare. Copyright 2015United HealthCare Services, Inc.
17
HCPCS
Procedure Code
L6696
L6697
L6698
L6703
L6704
L6706
L6707
L6708
L6709
L6711
L6712
L6713
L6714
L6715
L6721
L6722
L6805
L6810
L6880
L6881
L6882
L6883
L6884
L6885
L6890
Description
Addition to upper extremity prosthesis, below elbow/above elbow,
custom fabricated socket insert for congenital or atypical traumatic
amputee, silicone gel, elastomeric or equal, for use with or without
locking mechanism, initial only (for other than initial, use code l6694
or l6695)
Addition to upper extremity prosthesis, below elbow/above elbow,
custom fabricated socket insert for other than congenital or atypical
traumatic amputee, silicone gel, elastomeric or equal, for use with or
without locking mechanism, initial only (for other than initial, use code
l6694 or l6695)
Addition to upper extremity prosthesis, below elbow/above elbow,
lock mechanism, excludes socket insert
Terminal device, passive hand/mitt, any material, any size
Terminal device, sport/recreational/work attachment, any material,
any size
Terminal device, hook, mechanical, voluntary opening, any material,
any size, lined or unlined
Terminal device, hook, mechanical, voluntary closing, any material,
any size, lined or unlined
Terminal device, hand, mechanical, voluntary opening, any material,
any size
Terminal device, hand, mechanical, voluntary closing, any material,
any size
Terminal device, hook, mechanical, voluntary opening, any material,
any size, lined or unlined, pediatric
Terminal device, hook, mechanical, voluntary closing, any material,
any size, lined or unlined, pediatric
Terminal device, hand, mechanical, voluntary opening, any material,
any size, pediatric
Terminal device, hand, mechanical, voluntary closing, any material,
any size, pediatric
Terminal device, multiple articulating digit, includes motor(s), initial
issue
Terminal device, hook or hand, heavy-duty, mechanical, voluntary
opening, any material, any size, lined or unlined
Terminal device, hook or hand, heavy-duty, mechanical, voluntary
closing, any material, any size, lined or unlined
Addition to terminal device, modifier wrist unit
Addition to terminal device, precision pinch device
Electric hand, switch or myolelectric controlled, independently
articulating
Automatic grasp feature, addition to upper limb electric prosthetic
terminal device
Microprocessor control feature, addition to upper limb prosthetic
terminal device
Replacement socket, below elbow/wrist disarticulation, molded to
patient model, for use with or without external power
Replacement socket, above elbow/elbow disarticulation, molded to
patient model, for use with or without external power
Replacement socket, shoulder disarticulation/interscapular thoracic,
molded to patient model, for use with or without external power
Addition to upper extremity prosthesis, glove for terminal device, any
material, prefabricated, includes fitting and adjustment
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
Proprietary Information of UnitedHealthcare. Copyright 2015United HealthCare Services, Inc.
18
HCPCS
Procedure Code
Description
Addition to upper extremity prosthesis, glove for terminal device, any
material, custom fabricated
Hand restoration (casts, shading and measurements included), partial
L6900
hand, with glove, thumb or one finger remaining
Hand restoration (casts, shading and measurements included), partial
L6905
hand, with glove, multiple fingers remaining
Hand restoration (casts, shading and measurements included), partial
L6910
hand, with glove, no fingers remaining
Hand restoration (shading and measurements included), replacement
L6915
glove for above
EXTERNAL POWER: UPPER LIMB PROSTHETICS
Wrist disarticulation, external power, self-suspended inner socket,
L6920
removable forearm shell, otto bock or equal switch, cables, 2 batteries
and 1 charger, switch control of terminal device
Wrist disarticulation, external power, self-suspended inner socket,
L6925
removable forearm shell, otto bock or equal electrodes, cables, 2
batteries and one charger, myoelectronic control of terminal device
Below elbow, external power, self-suspended inner socket,
L6930
removable forearm shell, otto bock or equal switch, cables, 2 batteries
and one charger, switch control of terminal device
Below elbow, external power, self-suspended inner socket,
L6935
removable forearm shell, otto bock or equal electrodes, cables, 2
batteries and one charger, myoelectronic control of terminal device
Elbow disarticulation, external power, molded inner socket, removable
humeral shell, outside locking hinges, forearm, otto bock or equal
L6940
switch, cables, 2 batteries and one charger, switch control of terminal
device
Elbow disarticulation, external power, molded inner socket, removable
humeral shell, outside locking hinges, forearm, otto bock or equal
L6945
electrodes, cables, 2 batteries and one charger, myoelectronic control
of terminal device
Above elbow, external power, molded inner socket, removable
humeral shell, internal locking elbow, forearm, otto bock or equal
L6950
switch, cables, 2 batteries and one charger, switch control of terminal
device
Above elbow, external power, molded inner socket, removable
humeral shell, internal locking elbow, forearm, otto bock or equal
L6955
electrodes, cables, 2 batteries and one charger, myoelectronic control
of terminal device
Shoulder disarticulation, external power, molded inner socket,
removable shoulder shell, shoulder bulkhead, humeral section,
L6960
mechanical elbow, forearm, otto bock or equal switch, cables, 2
batteries and one charger, switch control of terminal device
Shoulder disarticulation, external power, molded inner socket,
removable shoulder shell, shoulder bulkhead, humeral section,
L6965
mechanical elbow, forearm, otto bock or equal electrodes, cables, 2
batteries and one charger, myoelectronic control of terminal device
Interscapular-thoracic, external power, molded inner socket,
removable shoulder shell, shoulder bulkhead, humeral section,
L6970
mechanical elbow, forearm, otto bock or equal switch, cables, 2
batteries and one charger, switch control of terminal device
L6895
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
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HCPCS
Procedure Code
Description
Interscapular-thoracic, external power, molded inner socket,
removable shoulder shell, shoulder bulkhead, humeral section,
L6975
mechanical elbow, forearm, otto bock or equal electrodes, cables, 2
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
L7040
Prehensile actuator, switch controlled
L7045
Electric hook, switch or myoelectric controlled, pediatric
L7170
Electronic elbow, hosmer or equal, switch controlled
Electronic elbow, microprocessor sequential control of elbow and
L7180
terminal device
Electronic elbow, microprocessor simultaneous control of elbow and
L7181
terminal device
Electronic elbow, adolescent, variety village or equal, switch
L7185
controlled
L7186
Electronic elbow, child, variety village or equal, switch controlled
Electronic elbow, adolescent, variety village or equal,
L7190
myoelectronically controlled
Electronic elbow, child, variety village or equal, myoelectronically
L7191
controlled
L7259
Electronic wrist rotator, any type
ADDITIONS TO UPPER EXTREMITY
Addition to upper extremity prosthesis, below elbow/wrist
L7400
disarticulation, ultralight material (titanium, carbon fiber or equal)
Addition to upper extremity prosthesis, above elbow disarticulation,
L7401
ultralight material (titanium, carbon fiber or equal)
Addition to upper extremity prosthesis, shoulder
L7402
disarticulation/interscapular thoracic, ultralight material (titanium,
carbon fiber or equal)
Addition to upper extremity prosthesis, below elbow/wrist
L7403
disarticulation, acrylic material
Addition to upper extremity prosthesis, above elbow disarticulation,
L7404
acrylic material
Addition to upper extremity prosthesis, shoulder
L7405
disarticulation/interscapular thoracic, acrylic material
L7499
Upper extremity prosthesis, not otherwise specified
PROSTHETIC SOCKS
L7600
Prosthetic donning sleeve, any material, each
L8400
Prosthetic sheath, below knee, each
L8410
Prosthetic sheath, above knee, each
L8415
Prosthetic sheath, upper limb, each
Prosthetic sheath/sock, including a gel cushion layer, below knee or
L8417
above knee, each
L8420
Prosthetic sock, multiple ply, below knee, each
L8430
Prosthetic sock, multiple ply, above knee, each
L8435
Prosthetic sock, multiple ply, upper limb, each
L8440
Prosthetic shrinker, below knee, each
L8460
Prosthetic shrinker, above knee, each
L8465
Prosthetic shrinker, upper limb, each
L8470
Prosthetic sock, single ply, fitting, below knee, each
L8480
Prosthetic sock, single ply, fitting, above knee, each
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
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HCPCS
Procedure Code
L8485
L8499
Description
Prosthetic sock, single ply, fitting, upper limb, each
Unlisted procedure for miscellaneous prosthetic services
Orthotic and prosthetic supply, accessory, and/or service component
of another HCPCS l code sales tax, orthotic/prosthetic/other office
L9900
visits with two or more modalities to the same area, initial 30 minutes,
each visit
REPAIR AND REPLACEMENT
L7510
Repair of prosthetic device, repair or replace minor parts
L7520
Repair prosthetic device, labor component, per 15 minutes
MISCELLANEOUS
L8510
Voice amplifier
WIGS
Please note: This is exclusion for 2001, but an optional buy up for 2007 and 2011.
A9282
Wig, any type, each
Limited to specific
diagnosis codes?
YES
NO
Limited to place of
service (POS)?
YES
NO
Limited to specific
provider type?
YES
NO
Limited to specific
revenue codes?
YES
NO
REFERENCES
1. BCBS of Alabama, Medical Policy #083-Microprocessor-Controlled Lower Limb
Prosthesis, Effective February 2010; Revised August 2013@
https://www.bcbsal.org/providers/policies/Accessed February 2, 2014
2. CGS Administrator, Lower Limb Prosthesis, L11442, Effective 01/01/2013
3. Noridian Jurisdiction D- DMERC LCD Lower Limb Prosthetics
http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
4. Össur [Website] Proprio Foot. Available at: http://www.ossur.com/?PageID=13460
Accessed February 2, 2013
GUIDELINE HISTORY/REVISION INFORMATION
Date
•
•
02/01/2015
Action/Description
Reorganized and renamed policy; combined content previously
outlined in the CDGs titled:
o Prosthetic Devices and Wigs
o Specialized, Microprocessor or Myoelectric Limbs
Revised coverage rationale/indications for coverage for prosthetic
devices and wigs; added language to indicate:
o A determination of coverage for the prosthesis is based on
the enrollee’s potential functional abilities
o Potential functional ability is based on the reasonable
expectations of the prosthetist and treating physician,
considering factors including, but not limited to:
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
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Date
Action/Description
The enrollee’s past history (including prior prosthetic use
if applicable); and
 The enrollee’s current condition including the status of
the residual limb and the nature of other medical
problems
Revised definitions; updated “Lower Limb Rehabilitation
Classification Levels”
o Added applicable “K-Level” headers/descriptors
o Updated description for “K-Level 0”
o Removed “VA requirements for computerized limbs”
Updated list of applicable HCPCS codes to reflect annual code
edits (effective 01/01/2015):
o Upper Limb Prosthetics:
 Added L6026
 Removed L6025
o External Power Upper Limb Prosthetics:
 Added L7259
 Removed L7260 and L7261
Archived previous policy version CDG.018.02

•
•
•
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs (Effective 02/01/2015)
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