L6036, Prosthetic thumb, mechanical, can include metacarpophalangeal (mcp),
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical Records Documentation Used for Reviews
Key Coverage Criteria
- Upper extremity prosthetic device is medically necessary when: (a) traumatic or surgical amputation or congenital absence; (b) prosthetic replaces all/part of missing limb; (c) prosthetic will help regain/maintain function; (d) device ordered by/under direction of physician; (e) needs evaluated by qualified professional annually; (f) patient willing/able to train; (g) rehabilitation potential with ADL/IADL assessment.
- An upper extremity prosthetic for amputations is proven and medically necessary when all of the following criteria are met: • 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 • Prosthetic will help the member regain or maintain function; and • Prosthetic device is ordered by or under the direction of a physician; and • Prosthetic needs have been evaluated for the member by a physic [...]
- Upper extremity prosthetic for amputations is proven and medically necessary when the member has a traumatic/surgical upper-extremity amputation or congenital absence; the prosthetic replaces all or part of a missing limb; it will help regain/maintain function; the device is ordered by a physician; needs have been evaluated annually by qualified professional; member is willing to participate in training; and functional assessment including ADLs/Instrumental ADLs is performed
3 Active Policies
UHC-POL-upper-extremity-prosthetic-devices, Upper Extremity Prosthetic Devices
UMR-POL-UMR-upper-extremity-prosthetic-devices, Upper Extremity Prosthetic Devices
SUREST-POL-SUREST-upper-extremity-prosthetic-devices, Upper Extremity Prosthetic Devices
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.