Does L7008 require prior authorization?

No, L7008 does not require prior authorization (high confidence). Code is covered without prior authorization.

`L7008`, Electric hand, switch or myoelectric, controlled, pediatric

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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).

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.
Myoelectric upper extremity prosthetic devices are consideredmedically necessarywhen ALL of the criteria below have been met:
The individual has an amputation or absence of a portion of an arm;and
Clinical records, including assessment by a trained prosthetic clinician, support that the individual has sufficient ability to operate the myoelectric technology effectively;and
A body-powered prosthetic device cannot be used or is insufficient to meet the functional goals and needs of the individual;and
A myoelectric device is likely to help the individual regain or maintain function better than a standard body-powered prosthetic device;and

ANTHEM-GL-C169421, CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices

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

Ask Verity about documentation requirements, denial risks, or coverage in your state.