L6039 Passive custom digit/thumbPassive prosthetic digit or thumb prosthesis not including hand restoration partial hand, full or partial, custom made, any material, initial or replacement, per single passive prosthetic digit or thumb
25 of 25 payer prior-auth lists that name L6039 require prior authorization or set conditions: Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | prior auth under conditions | Prior authorization required only for prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000. | Sep 1, 2026 | Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 |
| Oxford Health Plans | Oxford Health Plans | All | prior auth under conditions | Prior authorization required only for orthotics codes listed with a retail purchase or cumulative rental cost of more than $500. | Oct 1, 2026 | Prior Authorization Requirements for Oxford Effective October 1, 2026 |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans CHP+ | CO | prior auth required | Oct 1, 2026 | Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026 | |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans Prime / RAE | CO | prior auth required | Oct 1, 2026 | Rocky Mountain Health Plans PRIME Effective October 1, 2026 | |
| Surest | Surest health plans | All | prior auth under conditions | Cost over $1,000 | Oct 1, 2026 | Prior Authorization Requirements for Surest Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Commercial | All | prior auth under conditions | Prior authorization required only for prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth required | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Mid-Atlantic Health Plans | All | prior auth under conditions | Prior authorization required only for prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare West commercial plans | All | prior auth under conditions | Prior authorization is required only for orthotics codes listed with a retail purchase or cumulative rental cost of more than $1,000. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare West commercial plans | All | prior auth under conditions | Prior authorization is required only for prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare of the River Valley | All | prior auth under conditions | Prior authorization required only for prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026 |
| UnitedHealthcare Community Plan | AHCCCS Complete Care (ACC) | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026 | |
| UnitedHealthcare Community Plan | ALTCS Developmentally Disabled | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | ALTCS Long Term Care | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Indiana Hoosier Care Connect | IN | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Indiana Hoosier Care Connect Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Indiana PathWays for Aging (MLTSS) | IN | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Indiana MLTSS Pathways Effective October 1, 2026 |
| UnitedHealthcare Community Plan | KanCare | KS | prior auth under conditions | Prior authorization is required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Kansas Medicaid Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Maryland HealthChoice | MD | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026 |
| UnitedHealthcare Community Plan | TennCare | TN | prior auth under conditions | Prior authorization is required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Florida | FL | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Oct 1, 2026 | Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Hawaii (QUEST Integration) | HI | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of New York | NY | prior auth under conditions | Prior authorization is required only for the orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Virginia Cardinal Care LTSS | VA | prior auth under conditions | Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Virginia Cardinal Care Medicaid | VA | prior auth under conditions | Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026 |
L6039 appears in 13 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Capital Blue Cross, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Upper Limb Prostheses (0399) | covered if criteria are met | Jul 16, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Prosthetics (L.1.04.401) | covered if criteria are met | payer document | |
| Capital Blue Cross | Upper Limb Prostheses (MP 6.052) Procedure codes | covered if criteria are met | Apr 1, 2026 | payer document |
| UnitedHealthcare | State-Specific Criteria (CS360IN.03) Upper Limb Prosthetics | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Upper Extremity Prosthetic Devices (2026T0641I) Upper Limb Prosthetics | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Upper Extremity Prosthetic Devices (CS360.E) Upper Limb Prosthetics | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Upper Extremity Prosthetic Devices (for Kansas Only) (CS360KS.03) Upper Limb Prosthetics | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Upper Extremity Prosthetic Devices (for Kentucky Only) (CS360KY.05) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Upper Extremity Prosthetic Devices (for Nebraska Only) (CS360NE.E) Upper Limb Prosthetics | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Upper Extremity Prosthetic Devices (for New Mexico Only) (CS360NM.D) Upper Limb Prosthetics | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Upper Extremity Prosthetic Devices (for Ohio Only) (CS360OH.F) Upper Limb Prosthetics | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Upper Extremity Prosthetic Devices (for Pennsylvania Only) (CS360PA.E) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Upper Extremity Prosthetic Devices (for Tennessee Only) (CS360TN.E) Upper Limb Prosthetics | listed, no stance | Jun 1, 2026 | payer document |
Prior authorization required or conditional in CO, IN, MD, NE, OH, VA.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.