Does L7404 require prior authorization?

No, L7404 does not require prior authorization (high confidence). Code is covered without prior authorization.

`L7404`, Addition to upper extremity prosthesis, above elbow disarticulation, acrylic

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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 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 the 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 have been evaluated for the member by a physic [...]
Upper extremity prosthetic for amputations is proven and medically necessary when the member has a traumatic/surgical upper-extremity amputation or congenital absence; the prosthetic replaces all or part of a missing limb; it will help regain/maintain function; the device is ordered by a physician; needs have been evaluated annually by qualified professional; member is willing to participate in training; and functional assessment including ADLs/Instrumental ADLs is performed

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

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