Does L7181 require prior authorization?

Yes, L7181 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

`L7181`, Electronic elbow, microprocessor simultaneous control of elbow and terminal

HCPCS/CPT

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Coverage determinations must include review of the member's benefit contract or SPD for coverage vs. non-coverage, exclusions, and limitations (e.g., dollar or duration caps).
Documentation must include demonstration that residual musculature meets the minimum microvolt threshold, shown by functional testing using a physical or computer model prosthesis.
Documentation must include a functional evaluation by a qualified professional (e.g., prosthetist) concluding that, with training, a myoelectric prosthesis is necessary to meet the individual's functional needs; the evaluation should address control, durability, function, and usability, and affirm both subcriteria (device necessary for functional needs and not primarily for leisure).

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

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

UHC-POL-upper-extremity-prosthetic-devices, Upper Extremity Prosthetic Devices

BCBSIL-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb

BCBSMT-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb

BCBSNM-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb

BCBSOK-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb

REGENCE-DME80, Myoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper Limb

UMR-POL-UMR-upper-extremity-prosthetic-devices, Upper Extremity Prosthetic Devices

SUREST-POL-SUREST-upper-extremity-prosthetic-devices, Upper Extremity Prosthetic Devices