L6955, Above elbow, external power, molded inner socket, removable humeral shell,
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Documentation Required
- When billing articulating digits and prosthetic hands (e.g., codes L6715, L6880), product information such as manufacturer, part number or part name must be recorded in the medical records, and only products with a PDAC coding verification review (CVR) published on the Product Classification List may be billed with certain HCPCS codes; documentation submitted to PDAC must follow PDAC requirements.
- Documentation that items billed for replacement are not under manufacturer warranty (items under manufacturer warranty are considered not medically necessary).
- Documentation that repairs or adjustments are required due to bone growth or reasonable weight change or normal wear and tear when claiming repair/replacement.
- For powered base items and add-ons, documentation should support that batteries/battery chargers are billed appropriately (no separate payment when billed concurrently with a powered base item).
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 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).
- Replacement of medically necessary prosthetic devices when repairs or adjustments fail and/or are not possible.
- Myoelectric upper limb prostheses and hand prostheses are medically necessary for members with traumatic amputation or congenital absence of upper limb at the wrist or above (e.g., forearm or elbow) when all of the following criteria are met: Person has adequate cognitive and neurologic ability to utilize a myoelectric prosthetic device; and The remaining musculature of the arm(s) contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device; and A standard body- [...]
13 Active Policies
ANTHEM-GL-C169421, CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
UHC-POL-upper-extremity-prosthetic-devices, Upper Extremity Prosthetic Devices
AETNA-CPB-0399, Upper Limb Prostheses
DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSIL-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
Related Codes
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