L6697 — 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)
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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