L6621, Upper extremity prosthesis addition, flexion/extension wrist with or without
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation demonstrating inability of standard body-powered prosthesis to meet functional needs (e.g., trial notes, therapy reports).
- Objective evidence of adequate muscle signal (minimum microvolt threshold) to operate a myoelectric device (e.g., EMG or equivalent testing).
- Assessment documenting sufficient neurological and cognitive function to operate the prosthesis.
- Medical history and records documenting absence of comorbidities that would interfere with prosthesis function (e.g., neuromuscular disease).
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.
- Coverage required for an orthotic device or orthotic service for HCSC members residing in Arkansas under AR § 23-99-417.
- Coverage required for a prosthetic device or prosthetic service for HCSC members residing in Arkansas under AR § 23-99-417.
- Coverage required for a prosthetic device for athletics or recreation (defined as a device that enables ambulation exceeding basic ambulation skills, with high impact/stress/energy levels, including blade-type running feet).
- Coverage required for a prosthetic device for showering or bathing for HCSC members residing in Arkansas.
- Candidate for a recreational prosthesis must meet Medicare functional level K-3 or K-4 and: (1) be capable of achieving high-level activity pursuits; and (2) exhibit ability to perform above and beyond normal ambulation.
8 Active Policies
UHC-POL-upper-extremity-prosthetic-devices, Upper Extremity Prosthetic Devices
DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSIL-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSMT-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSNM-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
Related Codes
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