L6695 — 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
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage (see 'Medical Records Documentation Used for Reviews').
- Physician order for the prosthetic device or order under the direction of a physician.
- Evaluation and documentation by a healthcare professional with appropriate prosthetic qualifications and training (prosthetist) under the supervision of the ordering physician.
- Documentation that the prosthetic replaces all or part of a missing limb (identification of amputation level or congenital absence/defect).
Key Coverage Criteria
- 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 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 evaluated for member by a healthcare professional with appro [...]
- An upper extremity Myoelectric Prosthetic for amputations above the wrist is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Durable Medical Equipment, Prosthetics, Myoelectric, Upper Extremity, Above the Wrist (Custom) - UHG.
- An upper extremity Myoelectric Prosthetic hand, partial-hand, or artificial digit(s) for amputations below the wrist is medically necessary when all of the following criteria are met: Member has a traumatic or surgical amputation below the wrist or a congenital missing or dysfunctional hand or finger; and Prosthetic replaces all or part of a missing limb; and Prosthetic will help the member regain or maintain function; and Prosthetic needs evaluated for member by a healthcare professional with a [...]
- An orthosis (orthopedic brace) and/or prosthesis is medically necessary when: Care is prescribed by a physician, nurse practitioner, podiatrist or other health professional who is qualified to prescribe orthotics and/or prosthetics according to State law; and The orthosis or prosthesis will significantly improve or restore physical functions required for mobility related activities of daily living (MRADL's); and The member’s participating physician or licensed health care practitioner has determ [...]
- Artificial arms (whole extremity or a portion thereof).
- Artificial terminal devices (e.g., hand, hook, finger).
4 Active Policies
AETNA-CPB-0399 — Upper Limb Prostheses
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
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